Joseph Forbes Black
PFD Report
All Responded
Ref: 2025-0005
All 2 responses received
· Deadline: 27 Feb 2025
Coroner's Concerns (AI summary)
Naloxone kits are not widely available to drug users, especially those not engaged with substance misuse services, despite the increased risk from potent synthetic opioids.
View full coroner's concerns
The MATTER OF CONCERN is, as follows:
For context, on 26 July 2023, the Office for Health Improvement & Disparities issued a ‘National Patient Safety Alert’ (Ref no.: NatPSA/2023/009/OHID) (‘the Alert’). The Alert was entitled ‘Potent synthetic opioids implicated in heroin overdoses and deaths’ and it referred to known nationwide incidents of so-called ‘nitazenes’ having been found in batches of heroin. The Alert required, certain healthcare providers, to raise awareness of the heightened risks to anyone who may use drugs.
There was clear evidence that the risks raised by the Alert were communicated to Mr Forbes Black within the timeframes required. They were communicated by a mental health nurse, who was treating Mr Forbes Black in relation to his schizophrenia.
Naloxone, the ‘antidote’ for opioid overdoses, was not administered in Mr Forbes Black case. This because the circumstances in which he was found did not indicate that the administration of naloxone would be of any use in this instance. Staff at the supported accommodation where Mr Forbes Black lived, had naloxone that they could administer to residents if the staff came across a situation in which the administration was indicated.
The evidence revealed that, neither the supported accommodation provider nor the mental health NHS Trust that was treating Mr Forbes Black were permitted to give naloxone kits to their residents/patients who were known drug users.
In my experience, from this inquest and others, a significant proportion of illicit drug users are not engaged with or decline to engage with substance misuse services for a number of possible reasons. The evidence in the inquest was that, if a drug-user wanted to have naloxone in their possession as a safety-net measure, they would need to obtain this from a local substance misuse service.
I am concerned that this set of circumstances raises the risk of future deaths occurring because the provision of naloxone kits could be made more widely available to those most likely to need them. The present situation appears to be that naloxone is most easily accessed through the very service(s) that many drug-users are not engaged with. My concern, based on the evidence heard at this inquest and others that I am aware of, is that this is not a localised matter and is more likely a nationwide issue and that action should be taken more widely.
It further seems to me that the need for action is heightened by the increased incidence of heroin having been adulterated with ‘nitazenes’ (particularly potent synthetic opioid drugs), which increases the risk of drug users unwittingly overdosing.
For context, on 26 July 2023, the Office for Health Improvement & Disparities issued a ‘National Patient Safety Alert’ (Ref no.: NatPSA/2023/009/OHID) (‘the Alert’). The Alert was entitled ‘Potent synthetic opioids implicated in heroin overdoses and deaths’ and it referred to known nationwide incidents of so-called ‘nitazenes’ having been found in batches of heroin. The Alert required, certain healthcare providers, to raise awareness of the heightened risks to anyone who may use drugs.
There was clear evidence that the risks raised by the Alert were communicated to Mr Forbes Black within the timeframes required. They were communicated by a mental health nurse, who was treating Mr Forbes Black in relation to his schizophrenia.
Naloxone, the ‘antidote’ for opioid overdoses, was not administered in Mr Forbes Black case. This because the circumstances in which he was found did not indicate that the administration of naloxone would be of any use in this instance. Staff at the supported accommodation where Mr Forbes Black lived, had naloxone that they could administer to residents if the staff came across a situation in which the administration was indicated.
The evidence revealed that, neither the supported accommodation provider nor the mental health NHS Trust that was treating Mr Forbes Black were permitted to give naloxone kits to their residents/patients who were known drug users.
In my experience, from this inquest and others, a significant proportion of illicit drug users are not engaged with or decline to engage with substance misuse services for a number of possible reasons. The evidence in the inquest was that, if a drug-user wanted to have naloxone in their possession as a safety-net measure, they would need to obtain this from a local substance misuse service.
I am concerned that this set of circumstances raises the risk of future deaths occurring because the provision of naloxone kits could be made more widely available to those most likely to need them. The present situation appears to be that naloxone is most easily accessed through the very service(s) that many drug-users are not engaged with. My concern, based on the evidence heard at this inquest and others that I am aware of, is that this is not a localised matter and is more likely a nationwide issue and that action should be taken more widely.
It further seems to me that the need for action is heightened by the increased incidence of heroin having been adulterated with ‘nitazenes’ (particularly potent synthetic opioid drugs), which increases the risk of drug users unwittingly overdosing.
Responses
Action Taken
The Department of Health and Social Care amended the Human Medicines Regulations 2012 to expand access to naloxone beyond drug and alcohol treatment services, increasing the number of services and professionals able to give out take-home naloxone. (AI summary)
The Department of Health and Social Care amended the Human Medicines Regulations 2012 to expand access to naloxone beyond drug and alcohol treatment services, increasing the number of services and professionals able to give out take-home naloxone. (AI summary)
View full response
Dear Mr Potter,
Thank you for the Regulation 28 report of 2nd January 2025 sent to the Secretary of State, Department of Health and Social Care about the death of Joseph Forbes Black. I am replying as the Minister with responsibility for Public Health and Prevention.
Firstly, I would like to say how saddened I was to read of the circumstances of Joseph Forbes Black’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.
The report raises concerns over the availability of naloxone to those at risk of opioid overdose and the lack of services that are legally permitted to distribute take-home naloxone to those at risk. The report raises concerns over substance misuse services being the only route legally permitted to provide naloxone without a prescription, a service which many drug users are not engaged with.
I agree that it is vital that we expand access to this life-saving medication. We know that over half of people struggling with opiate addiction are not engaged in treatment at all. This means that significant numbers of an incredibly vulnerable population are at increased risk of accidentally overdosing and dying.
I am pleased to say that we have already taken action on this critical issue. On 2nd December 2024, the Government amended the Human Medicines Regulations 2012 to expand access to naloxone beyond drug and alcohol treatment services. There are two key changes in the legislation to be aware of. The first increases the number of services and professionals specified in the regulations that are able to give out take home naloxone (for example nurses, paramedics, police offers and probation officers) therefore increasing the likelihood of those who are most vulnerable receiving it, regardless of whether they are engaged in drug and alcohol treatment. The second enables the creation of a registration service for services and professionals that could not be explicitly named in the legislation through route one – for example, supported accommodation services. These changes aim to capture more services
and professionals who may encounter those at risk of opioid overdose, including the services you have rightly pointed out as important services to distribute take-home naloxone. We continue to monitor and respond to the threat posed by synthetic opioids, including nitazenes, and we are taking a lead role in the cross Government Synthetic Opioids Taskforce. We remain committed to increasing the numbers in treatment for opiates and enhancing our surveillance system which monitors changing drugs markets and drug related harm. Part of that surveillance system includes a toxicology data collection. Many toxicology labs, with the support of their Coroners, are providing us with pre-inquest toxicology information to allow for more timely monitoring and response to drugs causing deaths. We would strongly encourage you to consider participating by confirming with your toxicology provider that they can share relevant reports with the Office for Health Improvement and Disparities. I hope this response is helpful. Thank you for bringing these concerns to my attention.
Thank you for the Regulation 28 report of 2nd January 2025 sent to the Secretary of State, Department of Health and Social Care about the death of Joseph Forbes Black. I am replying as the Minister with responsibility for Public Health and Prevention.
Firstly, I would like to say how saddened I was to read of the circumstances of Joseph Forbes Black’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.
The report raises concerns over the availability of naloxone to those at risk of opioid overdose and the lack of services that are legally permitted to distribute take-home naloxone to those at risk. The report raises concerns over substance misuse services being the only route legally permitted to provide naloxone without a prescription, a service which many drug users are not engaged with.
I agree that it is vital that we expand access to this life-saving medication. We know that over half of people struggling with opiate addiction are not engaged in treatment at all. This means that significant numbers of an incredibly vulnerable population are at increased risk of accidentally overdosing and dying.
I am pleased to say that we have already taken action on this critical issue. On 2nd December 2024, the Government amended the Human Medicines Regulations 2012 to expand access to naloxone beyond drug and alcohol treatment services. There are two key changes in the legislation to be aware of. The first increases the number of services and professionals specified in the regulations that are able to give out take home naloxone (for example nurses, paramedics, police offers and probation officers) therefore increasing the likelihood of those who are most vulnerable receiving it, regardless of whether they are engaged in drug and alcohol treatment. The second enables the creation of a registration service for services and professionals that could not be explicitly named in the legislation through route one – for example, supported accommodation services. These changes aim to capture more services
and professionals who may encounter those at risk of opioid overdose, including the services you have rightly pointed out as important services to distribute take-home naloxone. We continue to monitor and respond to the threat posed by synthetic opioids, including nitazenes, and we are taking a lead role in the cross Government Synthetic Opioids Taskforce. We remain committed to increasing the numbers in treatment for opiates and enhancing our surveillance system which monitors changing drugs markets and drug related harm. Part of that surveillance system includes a toxicology data collection. Many toxicology labs, with the support of their Coroners, are providing us with pre-inquest toxicology information to allow for more timely monitoring and response to drugs causing deaths. We would strongly encourage you to consider participating by confirming with your toxicology provider that they can share relevant reports with the Office for Health Improvement and Disparities. I hope this response is helpful. Thank you for bringing these concerns to my attention.
Action Planned
NHS England notes that the responsibility for commissioning drug dependency services rests with local authorities and that the DHSC is the more appropriate organisation to respond. It also mentions that community pharmacies can now supply naloxone and that North Central London ICB will work with Camden Better Lives to highlight good practice for giving training on how it is administered. (AI summary)
NHS England notes that the responsibility for commissioning drug dependency services rests with local authorities and that the DHSC is the more appropriate organisation to respond. It also mentions that community pharmacies can now supply naloxone and that North Central London ICB will work with Camden Better Lives to highlight good practice for giving training on how it is administered. (AI summary)
View full response
Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Joseph Benjamin Forbes Black who died on 9 August 2023
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 2 January 2025 concerning the death of Joseph Benjamin Forbes Black on 9 August
2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Joseph’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Joseph’s care have been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused Joseph’s family or friends. I realise that responses to Coroners’ Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them.
Your Report raised the concern that naloxone kits are not more widely available nationally, and that a significant proportion of illicit drug users do not engage with substance misuse services, when it is these services that could supply naloxone.
The responsibility for commissioning drug dependency services rests with local authorities. I note that you have also addressed your Report to the Secretary of State for Health and Social Care, and it is their Department (DHSC) that is the more appropriate organisation to response to your concerns. Previous legislation meant that only drug and alcohol treatment services were able to supply naloxone for the indication described in this case. However, last year the DHSC consulted on widening access to naloxone: Expanding access to naloxone - GOV.UK. Following this, community pharmacies can now, in practice, provide take-home naloxone without a prescription to reverse potential opiate overdoses to those who need it. However, the scope of what local authorities choose to commission through community pharmacies also varies and there is currently no requirement for them to supply naloxone and this would be a decision for local government. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
19 March 2025
My regional Patient Safety colleagues for London have also engaged with Islington Better Lives, part of the North London NHS Foundation Trust, and commissioned by the London Borough of Islington council. Naloxone provision is a fundamental part of the service delivery and they have advised that they ensure maximum reach and distribution in the following ways:
• All opiate using clients are offered Naloxone as soon as they enter treatment and are given training on how it is administered.
• Clients are routinely given 2 x kits (either injectable or nasal spray or both) with a warning that they may require more naloxone if they or others overdose on heroin which has been mixed with Nitazines (Fentanyl etc.)
• All other clients are also offered Naloxone in case they encounter individuals in overdose.
• High risk groups are considered (e.g., hostel-dwelling and those in contact with criminal justice systems where release from prison increases risk of overdose). Supply of Naloxone is issued to an array of clients including in probation and court environments, as well as being made available at hostel receptions.
• The service actively encourages clients to access treatment by making this as easy as possible: being in treatment reduces some of the risks faced in terms of overdose. They aim to take a rapid access response where possible to work with clients at their optimum stage of motivation. While this describes Islington’s Better Lives service, North Central London Integrated Care Board (ICB) are going to work with Camden Better Lives to highlight this good practice. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Joseph, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 2 January 2025 concerning the death of Joseph Benjamin Forbes Black on 9 August
2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Joseph’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Joseph’s care have been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused Joseph’s family or friends. I realise that responses to Coroners’ Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them.
Your Report raised the concern that naloxone kits are not more widely available nationally, and that a significant proportion of illicit drug users do not engage with substance misuse services, when it is these services that could supply naloxone.
The responsibility for commissioning drug dependency services rests with local authorities. I note that you have also addressed your Report to the Secretary of State for Health and Social Care, and it is their Department (DHSC) that is the more appropriate organisation to response to your concerns. Previous legislation meant that only drug and alcohol treatment services were able to supply naloxone for the indication described in this case. However, last year the DHSC consulted on widening access to naloxone: Expanding access to naloxone - GOV.UK. Following this, community pharmacies can now, in practice, provide take-home naloxone without a prescription to reverse potential opiate overdoses to those who need it. However, the scope of what local authorities choose to commission through community pharmacies also varies and there is currently no requirement for them to supply naloxone and this would be a decision for local government. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
19 March 2025
My regional Patient Safety colleagues for London have also engaged with Islington Better Lives, part of the North London NHS Foundation Trust, and commissioned by the London Borough of Islington council. Naloxone provision is a fundamental part of the service delivery and they have advised that they ensure maximum reach and distribution in the following ways:
• All opiate using clients are offered Naloxone as soon as they enter treatment and are given training on how it is administered.
• Clients are routinely given 2 x kits (either injectable or nasal spray or both) with a warning that they may require more naloxone if they or others overdose on heroin which has been mixed with Nitazines (Fentanyl etc.)
• All other clients are also offered Naloxone in case they encounter individuals in overdose.
• High risk groups are considered (e.g., hostel-dwelling and those in contact with criminal justice systems where release from prison increases risk of overdose). Supply of Naloxone is issued to an array of clients including in probation and court environments, as well as being made available at hostel receptions.
• The service actively encourages clients to access treatment by making this as easy as possible: being in treatment reduces some of the risks faced in terms of overdose. They aim to take a rapid access response where possible to work with clients at their optimum stage of motivation. While this describes Islington’s Better Lives service, North Central London Integrated Care Board (ICB) are going to work with Camden Better Lives to highlight this good practice. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Joseph, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Sent To
- Department of Health and Social Care
- NHS England
Response Status
Linked responses
2 of 2
56-Day Deadline
27 Feb 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 17 August 2023, an investigation was commenced into the death of Joseph Benjamin FORBES BLACK, aged 39 years at the time of his death.
The investigation concluded at the end of an inquest on 23 December 2024.
The conclusion of the inquest was ‘drug-related death’.
The medical cause of death was: 1a acute polydrug toxicity (heroin, cocaine, metonitazine, protonitazine) 1b substance misuse disorder II mental health disorder
The investigation concluded at the end of an inquest on 23 December 2024.
The conclusion of the inquest was ‘drug-related death’.
The medical cause of death was: 1a acute polydrug toxicity (heroin, cocaine, metonitazine, protonitazine) 1b substance misuse disorder II mental health disorder
Circumstances of the Death
Joseph Forbes Black had a longstanding history of harmful substance misuse, against a backdrop of ‘unspecified schizophrenia’. He engaged well with the treatment of his schizophrenia and his mental health was considered stable in the time leading up to his death. However, despite being aware of available help, support, and treatment in relation to substance misuse, Mr Forbes Black repeatedly declined to engage.
On 9 August 2023, Mr Forbes Black was found deceased at his home address. He died as a result of acute polydrug toxicity, which included the taking of heroin that had been adulterated with protonitazene and metonitazene. The presence of ‘nitazenes’ more than minimally contributed to his death.
On 9 August 2023, Mr Forbes Black was found deceased at his home address. He died as a result of acute polydrug toxicity, which included the taking of heroin that had been adulterated with protonitazene and metonitazene. The presence of ‘nitazenes’ more than minimally contributed to his death.
Copies Sent To
North London NHS Foundation Trust
London Borough of Camden
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.