Michael Anthony
PFD Report
Partially Responded
Ref: 2014-0161
Coroner's Concerns (AI summary)
The coroner noted that the deceased's Gabapentin level was five times the normal therapeutic level, the reason for which was undetermined, and that the drug is usually not prescribed in diabetics due to the risk of severe reaction.
Responses
Action Taken
The trust has built a review of the case into their day to day practice and reported the case via the MHRA yellow card reporting system. The trust has also spoken to clinical leads regarding the use of the drug and side effects. (AI summary)
The trust has built a review of the case into their day to day practice and reported the case via the MHRA yellow card reporting system. The trust has also spoken to clinical leads regarding the use of the drug and side effects. (AI summary)
View full response
Dear Mr John Thompson Re: MR MCHAEL ANTHONY (DECEASED) Date of Birth: 15-05-1948 NHS No] Address Many thanks for your letter of 10lh April last sent to both myself and in relation to the above deceased: note and acknowledge receipt of the Regulation 28 report to prevent future deaths on the above addressed to myself and have asked for full disclosure by email to the coroner's office of the toxicologists report: In the meantime, we have asked for a review from the regional drug information service at Guy's. This is attached below and forms part of our reflection, learning and response_ We have spoken to Clinical Lead for Diabetes and Endocrinology at Guy's and St, Thomas' and Clinical Director for ihe Clinical Academic Grouping of Diabetes and Endocrinology in King's Health Partner, who does not recognise this particular risk and in his own extensive experience has not seen it and have conferred: We have used this drug over many years_ It is licensed for the use of the treatment of syndrome in diabetics have never had any problems such as described in the case_ We both note the comments by the Toxicologist, We have made the necessary changes by building this review into our day to practice. If there is any further comments to be added on receipt of the disclosure requested above, we will reply but at present we would ask that this letter serves as our conclusion and formal reply to the letter received from you on behalf of the Chief Coroner.
Sent To
Response Status
Linked responses
1 of 2
56-Day Deadline
4 Jun 2014
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 14.05.13 [ opened an inquest into the death of Michael Anthony, aged 64, who died on 8th May 2013. The inquest was concluded on 26" March 2014. The conclusion of the inquest was given in a narrative: Mr Anthony was found dead in his flat on &h May 2013. There were no suspicious circumstances: He died diabetic ketoacidotic coma. He a very high Gabapentin level in his blood, which along with a fatty liver from Hepatitis B andlor diabetes, contributed to his death. It was not possible to conclude whether the ketoacidosis was also caused by a reaction to Gabapentin.
Circumstances of the Death
The Gabapentin level was five times normal therapeutic level. It was not determined why this level was so high. His ketonuria was reported by the toxicologist as either being due to diabetic coma (shortage of insulin) andlor a reaction to the drug Gabapentin. The toxicologist reported that Gabapentin was usually not prescribed in diabetics_ as some individuals developed a severe reaction which precipitated diabetic coma: The court read the evidence of the GP, who did not refer to the reasons for prescribing Gabapentin and did not call the consultant physician, but heard it was for pain relief:
Action Should Be Taken
The doctors are asked to review the prescribing of this and its consider whether it is appropriate to update their indications and prescribing knowledge and practice_
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.