On 28 July 2020, I commenced an investigation into the death of Lee Derek Jamie ADAMS, aged 36. The investigation concluded at the end of the inquest on 7 November 2025. The conclusion of the inquest was that: [taken from Section 4 of the Record of Inquest] Lee was suffering from a long-term depressive illness. He also partook in on-line gambling. On 24.7.2020 he took an excessive number of propranolol tablets, intending to take his own life. In the preceding few months - in Covid lockdown - he had become increasingly reliant and involved with gambling. He was contacted in late March about his deposits, he had stated he was fine. He continued to gamble. He was not identified as being at increased risk. I concluded Lee’s medical cause of death [Section 2] to be: 1a. Cardiac arrhythmia 1b. Propranolol overdose 1c. Gambling disorder II. Depressive illness

Lee was at home alone and had been gambling extensively over the evening/night/ early morning of 23/24 July 2020. The last time propranolol had been given by prescription was in 2017; it was not clear where he had obtained the medication. He called 999 in the early hours saying he had taken some tablets of unknown origin, an ambulance was dispatched arriving on scene some 10 minutes later and then with him 23 minutes later. As, by that time, Lee had been unable to let the crew in, and the police were tasked with assisting and gaining entry. By the time of entry, Lee status had deteriorated significantly: seizing and with shallow breathing. In a short time, CPR had to commence. At this stage the tableted medication was still unknown; naloxone was given once, to no effect. Sadly, he was pronounced dead at 03.39 Subsequent post-mortem and toxicology revealing the presence of propranolol in Lee stomach and blood. Expert evidence provided to the court was that once the significant amount of Beta-Blocker had been taken (propranolol) the outcome was inevitable; there being no opportunity to save his life.