Susan Poore
PFD Report
Historic (No Identified Response)
Ref: 2014-0140
Coroner's Concerns (AI summary)
Anti-depressant medication was associated with a deterioration in the patient's depression, leading to an uncharacteristic death, despite side-effect warnings.
View full coroner's concerns
_ (1) Shortly before her death, Mrs Poore had been prescribed anti-depressant medication (Mirtazapine 29.03.2012 changed to Fluoxeline 23.04.2012) (2) The evidence is that her depression deteriorated following her taking the anti-depressant medication and the mode of death was out of character for Mrs Poore (3) Although the medication did conlain a message warning of the potential side-effect of worsening depression, (his did not prevent Mrs Poore's death Box May
Sent To
- NHS England
Response Status
Linked responses
0 of 1
56-Day Deadline
23 May 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 8t May 2012 commenced an investigation into the death of Susan Edena Poore The investigation concluded at the end of (he inquest on 18th March 2014_ The conclusion of (he inquest was Mrs Poore stepped in front of a train and suffered fatal injuries. At the time Mrs Poore was taking anti-depressant medicalion_ The medical cause of death was "Multiple Trauma due to collision with a train"_
Circumstances of the Death
On 3 2012, Mrs Poore's family reported to local Police Ihat she was missing; During that morning a (rain driver saw a person standing on the line near Thains Lane; East Runton: He reports that he sounded his horn but the person did not move. Despite applying his brakes Ihe Irain did not stop quickly enough and struck Ihe person causing falal injuries_ The person was later identified as Mrs Poore. Mrs Poore had recently been prescribed anti-depressant medication.
Action Should Be Taken
In my opinion action should be taken t0 prevent future deaths and believe your organisation has the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.