R (Jones) v HM Coroner for South London and Virdi [Administrative Court]
| Jurisdiction | England & Wales |
| Judgment Date | 28 April 2010 |
| Date | 28 April 2010 |
| Court | Queen's Bench Division (Administrative Court) |
Administrative Court, CO/13988/2009
Toulson LJ, Owen J
N Brown (instructed by Colemans-ctts) for the claimant; P Matthews (instructed by Withers) for the defendant.
Whether there had been insufficiency of inquiry where the scope of an inquest had been limited to the last link in the chain of causation; whether a new inquest should be held.
The claimant's son had been prescribed an oral preparation of morphine for abdominal pain by an out of hours doctor. Two days later another out of hours doctor prescribed him two 72 hour fentanyl patches (a strong opioid painkiller) which the deceased had not previously been prescribed. The following day a repeat prescription of two 72 hour fentanyl patches was given and the next day his GP (the interested party) also prescribed him a further two fentanyl patches. Three days later the deceased was found dead in bed. At post-mortem blood levels of fentanyl of approximately 15 to 20 times the average fatal dose were found and the cause of death was given as fentanyl toxicity.
At the inquest oral evidence was heard from the claimant, the pathologist conducting the post-mortem, the police officer in charge of enquiries into the death and the interested party. The coroner returned an open verdict, stating that it was difficult to explain the particularly high level of fentanyl on the basis of the amount that had been prescribed. After the inquest it came to light, through the claimant's efforts, that a drug warning had been issued before the death following a review of 120 fatalities linked to unintentional overdoses of fentanyl.
The claimant applied under s13 Coroners Act 1988 for an order quashing the inquisition and for a new inquest to be heard by a different coroner. It was contended that the initial inquest had made insufficient inquiry in that it should have investigated how the deceased had such an extremely high concentration of fentanyl, and in particular whether it was possible that such a high concentration could have been attributable to the use of the prescribed patches. It was further submitted that it was necessary and desirable in the interests of justice that another inquest be held as there was a wider public interest in fully investigating this death from fentanyl toxicity in the light of the evidence that there had been a considerable number of deaths both in the USA and in the UK, that had been linked to unintended overdoses of fentanyl.
1. The applicant, Glennys Linda Jones, is the mother of David Brian Jones (the 'deceased') , who on the morning of 31 December 2005 was found dead at his home at 6 Mason Court, 12 Belvedere Road, London SE 19 by his partner, Andrew Anderson. She applies under s13 of the Coroners Act 1988 for an order quashing the inquisition in respect of the death of the deceased taken before the defendant, Dr Roy Palmer, HM Coroner for the Southern District of Greater London on 17 August 2006, and directing that another inquest be held by a different coroner. The application is made with the authority of HM Attorney General, granted by fiat issued on 18 October 2009. The interested party, Dr Deshminder Virdi, was the deceased's registered GP at the time of his death.
The factual background
2. The deceased was born on 22 May 1982, and was 23 years of age at the date of his death. In June 2005 the deceased registered with Dr Virdi. He had a complex medical history in that he suffered from Asperger's syndrome, and had also been diagnosed with probable ileocolonic Crohn's disease. On 23 December 2005 he visited the South East London Doctors on Call out of hours doctors service (Seldoc) requesting oramorph, an oral preparation of morphine, for abdominal pain. He was prescribed oramorph, 10mgs four times a day for 25 days. But on 25 December 2005 the deceased telephoned the Bromley out of hours on-call doctor service requesting fentanyl patches. Fentanyl is a strong opioid painkiller, which the deceased had not previously been prescribed. The duty doctor prescribed two 72 hour 50 mcg/hr fentanyl transdermal patches.
3. On the following day, 26 December, the deceased telephoned Croydoc, the Croydon Doctors on call out of hours service, asking for a repeat prescription of fentanyl transdermal patches. The duty doctor prescribed two 72 hour 100 mcg/hr fentanyl transdermal patches which the deceased collected on 29 December. On 30 December 2005 the deceased made nine calls to the NHS Direct, and on the same morning attended Dr Virdi's surgery, where he saw Dr Virdi who prescribed a further two 72 hour 100 mcg/hr fentanyl transdermal patches. He also prescribed 28 20 mg tablets of temazapam (a short acting benzodiazepine), and 28 4 mg tablets of chlorpheniramine maleate (an anti-histamine). The drugs were dispensed later that morning. Both the prescription collected on 29 December and that collected on 30 December were dispensed from the same pharmacy, Sefgrove Pharmacy, 3-5 Westow Hill, Upper Norwood. London SE 19.
4. The deceased's partner, Andrew Anderson, returned home at about 12:35am on 31 December 2005. The deceased had left a note on his bedroom door asking not to be disturbed, but Andrew Anderson heard the deceased breathing before he went to bed. Shortly before 9am Mr Anderson found the deceased dead in his bed. He called the emergency services, and a police doctor pronounced the deceased dead at 10:10am.
5. A post-mortem examination was carried out by Dr J Seet, a consultant pathologist, on 3 January 2006. Subsequent toxicology tests revealed that the concentration of fentanyl in the deceased's blood was 60 mcg/l and in his urine 580 mcg/l. In his report stated 20 March 2006, the toxicologist from the Medical Toxicology Laboratory who had tested the deceased's blood and urine samples, reported in the following terms -
"Serum fentanyl concentrations attained a range of 0.3 -- 1.2 mcg/l within 24 hours after application of a 25 mcg/hr transdermal patch; the ranges for the 50, 75 and 100 mcg/hr 0.6 - 1.8, 1.1 - 2.6, and 1.9 - 3.8 mcg/l respectively. Fentanyl concentrations in four adults who died from excessive use of transdermal fentanyl averaged 23 mcg/l(range 12-41) in blood and 233 mcg/l (range 89-449) in urine…"
Dr Seet gave her opinion as to cause of death as being "1(a). Fentanyl toxicity, 2. Pneumonia".
6. At the inquest on 17 August 2006, the coroner's officer, Mrs Colville, gave identification evidence. The other witnesses to give oral evidence were the claimant, Dr Seet, Detective Sgt Crosfield, the police officer in charge of enquiries into the death of the deceased, and the interested party. A witness statement that had been obtained by DS Crosfield from Mr Anderson was read. At the conclusion of the inquest the defendant gave the cause of death as "1(a) Fentanyl toxicity, 2 Pneumonia", and returned an open form conclusion.
7. In the course of summing up the evidence and giving his conclusions the defendant said, inter alia,
"What I cannot explain and what no one else can explain is why, if he had the fentanyl in the dose prescribed in slow release form, how did he manage to end up with the blood level of 60 mcg rather than expected level of somewhere between 2 or 3 point whatever it was?
In the end, as is so often the case, one never does get to the bottom of exactly how something happened, how he...
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