Mohammed Ahmed
PFD Report
Partially Responded
Ref: 2019-0093
Coroner's Concerns (AI summary)
Combined use of Olanzapine and Spice caused a fatal allergic reaction, yet Olanzapine continued to be prescribed. Clinicians may lack national awareness of serious drug interactions and side effects with Olanzapine.
View full coroner's concerns
_ : _ (1) The expert evidence of Emeritus of Forensic Medicine) gave evidence that the use of Spice can prime a person for an allergic reaction. In the case of Mr Ahmed Olanzapine and Spice combined to cause an adverse allergic reaction: He had been prescribed Olanzapine throughout his imprisonment in the knowledge of Spice use_ (2) Healthcare records demonstrated that his eosinophilia count was recorded as reduced following a change in medication from Olanzapine to Risperidone.
(3) The expert evidence was that it was a very rare side effect but one which the U.S Food and Drug Administration has warned that drug reaction with eosinophilia and systemic symptoms has been reported with olanzapine exposure (4) The jury was not able to find that the death was caused or contributed to by the use of Spice. It remains unclear whether the expert opinion is one which is or should be made known to clinicians nationally.
(3) The expert evidence was that it was a very rare side effect but one which the U.S Food and Drug Administration has warned that drug reaction with eosinophilia and systemic symptoms has been reported with olanzapine exposure (4) The jury was not able to find that the death was caused or contributed to by the use of Spice. It remains unclear whether the expert opinion is one which is or should be made known to clinicians nationally.
Responses
Noted
The Department of Health acknowledges the concerns but states that the MHRA considers current warnings for olanzapine to be adequate and will keep the issue under scrutiny. NHS England will encourage medical directors to remind prescribers of the risks highlighted within the SPC when prescribing antipsychotic medication to people who are known users of synthetic cannabinoids. (AI summary)
The Department of Health acknowledges the concerns but states that the MHRA considers current warnings for olanzapine to be adequate and will keep the issue under scrutiny. NHS England will encourage medical directors to remind prescribers of the risks highlighted within the SPC when prescribing antipsychotic medication to people who are known users of synthetic cannabinoids. (AI summary)
View full response
From the Baroness Blackwood Parllamentary Under Secretary of State far Innovalion Department of Health 39 Victoria Street London SWIH OEU 020 7210 4850 Our Ref: PFD-1171237 Ms Jacqueline Devonish HM Area Coroner; Suffolk Coroner's Office Beacon House 53-65 White House Road Ipswich IP] SPB 2$ June 2019 en M _erai L Thank you for your correspondence of 19 March to Matt Hancock about the death of Mr Mohammed Shabol Ahmed: Iam replying as Minister with responsibility for medicines and I am grateful for the additional time in which to do s0_ Firstly, I would like to say how saddened I was to read of the circumstances of Mr Ahmed's death: It is important that we look to make improvements where we can to ensure the safety of healthcare, including within the system, and I am grateful to you for bringing these matters to my attention: My officials have made enquiries with NHS England to which You also issued yOur report; and with the Medicines and Healthcare products Regulatory Authority (MHRA) which has responsibility, among others, to ensure medicines are efficacious and acceptably safe. [am advised by the MHRA that it considers the current warnings on the Summary of Product Characteristics (SPC) for olanzapine about adverse reactions of eosinophilia, and of drug reaction with eosinophilia and systemic symptoms with olanzapine appropriately address the nature of these risks, and given the absence of similar reported cases, does not intend to take further regulatory action at this time prison drug
The MHRA will keep the issue under scrutiny through its Yellow Card scheme. This is the system in the UK for collecting and monitoring information on suspected adverse reactions. The MHRA has added this case to its Yellow Card database (reference number ADR 24400766). The MHRA is running a national pilot in collaboration with Public Health England for reporting unexpected or severe illicit reactions The system is piloted to better understand the adverse effects of newer illicit Or new patterns of use, including alongside licensed medicines, and how these adverse effects might be treated , A further aim of the pilot is to reduce the length of time between related health harms emerging and developing effective treatment responses. Reports are analysed and examined alongside other data by a multi-disciplinary clinical network to determine emerging harms across the UK. A search of the database did not identify similar cases invol synthetic cannabinoids and olanzapine: However; again, the MHRA will keep this issue under scrutiny through the national Finally, I am aware that NHS England has responded to you directly to advise that it will encourage medical directors across the NHS to remind prescribers of the risks highlighted within the SPC when prescribing antipsychotic medication to people who are known users of synthetic cannabinoids, and to use the Yellow Card scheme to report future suspected cases of eosinophilic related reactions in patients prescribed olanzapine and who may have also taken a synthetic cannabinoid. I hope this response is helpful Nis Gx NICOLA BLACKWOOD drug drug- being - drugs drug- ving pilot: Ymr Scs-1
The MHRA will keep the issue under scrutiny through its Yellow Card scheme. This is the system in the UK for collecting and monitoring information on suspected adverse reactions. The MHRA has added this case to its Yellow Card database (reference number ADR 24400766). The MHRA is running a national pilot in collaboration with Public Health England for reporting unexpected or severe illicit reactions The system is piloted to better understand the adverse effects of newer illicit Or new patterns of use, including alongside licensed medicines, and how these adverse effects might be treated , A further aim of the pilot is to reduce the length of time between related health harms emerging and developing effective treatment responses. Reports are analysed and examined alongside other data by a multi-disciplinary clinical network to determine emerging harms across the UK. A search of the database did not identify similar cases invol synthetic cannabinoids and olanzapine: However; again, the MHRA will keep this issue under scrutiny through the national Finally, I am aware that NHS England has responded to you directly to advise that it will encourage medical directors across the NHS to remind prescribers of the risks highlighted within the SPC when prescribing antipsychotic medication to people who are known users of synthetic cannabinoids, and to use the Yellow Card scheme to report future suspected cases of eosinophilic related reactions in patients prescribed olanzapine and who may have also taken a synthetic cannabinoid. I hope this response is helpful Nis Gx NICOLA BLACKWOOD drug drug- being - drugs drug- ving pilot: Ymr Scs-1
Part of a Series
2 separate reports were issued from this inquest, each sent to different organisations.
-
2018-0230
Sent to: Department for HealthManchester University NHS TrustRCOGNo responses yet
This report (2019-0093) is shown above.
Sent To
- Department of Health and Social Care
- NHS England
Response Status
Linked responses
1 of 2
56-Day Deadline
9 Aug 2019
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 6 March 2019 commenced an investigation into the death of Mohammed Shabol AHMED, aged 33. The investigation concluded at the end of the inquest on 14 March 2019. The conclusion of the inquest was that the medical cause of death was unascertained and the conclusion Open_ The jury also made the following findings of fact which caused or contributed to the death: a) The system at the prison relied upon the hospital and healthcare to tell the prison what to do regarding prisoner welfare b) There was a serious failure in the sharing of information between the prison, healthcare and the hospital c) There was inadequate training in the prison to deal with drug related incidents and their aftermath
Circumstances of the Death
Shabol Ahmed, a long-term illicit drug user; had been imprisoned at HMP Highpoint South for offending behaviours linked to his drug use_ He was first imprisoned at the age of 18 and had been detained at different prisons_ At the time of his death he had been an inmate at Highpoint since 21 June 2012, with a period at HMP Grendon from August 2016 to January 2016. He arrived at Highpoint with a diagnosis of Schizophrenia for which he had been prescribed olanzapine_ He also had a Learning Disability. His olanzapine prescription was maintained in prison, although he was not always compliant: The evidence before the inquest was that he may have regularly used Spice in prison and had succumbed to the effects of it on at least three occasions On two of those occasions he collapsed activating a code blue on 27 May and 18 2016. On 18 July he collapsed at Spm: Healthcare attended and an ambulance transferred him to hospital. The effects of Spice were beginning to wear off by the the ambulance arrived at 5. At 6. the ambulance left the prison arriving at the hospital at Zpm When seen by the Consultant at 7.1Opm his observations were July time 15pm: 45pm normal. He required no treatment and was returned to the prison at 9.25pm with no requirements for observation overnight After having eaten he slept in his cell: The following morning at 6.2Oam Mr Ahmed was found deceased at roll call.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action:
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.