Jones v HM Coroner for the Southern District of Greater London & Anor [2010] EWHC 931 (Admin)

Case No CO/13988/2009[2010] EWHC 931 (Admin)QUEEN'S BENCH DIVISIONDIVISIONAL COURTVenue Royal Courts of Justice, Strand, London, WC2A 2LLDate 28/04/2010
Before
LORD JUSTICE TOULSONMR JUSTICE OWEN
Between
GLENNYS JONESClaimantHER MAJESTYS CORONER FOR THE SOUTHERN DISTRICT OF GREATER LONDONDefendantDR DESHMINDER VIRDIInterested Party
(Transcript of the Handed Down Judgment ofWordWave International LimitedA Merrill Communications Company165 Fleet Street, London EC4A 2DYTel No: 020 7404 1400, Fax No: 020 7404 1424Official Shorthand Writers to the Court)
Mr Nicholas R D Brown (instructed by Colemans-ctts) for ClaimantMr Paul Matthews Solicitor-Advocate (instructed by Withers) for DefendantHearing Hearing date: 3 March 2010
Judgment
[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 section 13 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.[2]The factual background 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 12:35 am 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 9 am Mr Anderson found the deceased dead in his bed. He called the emergency services, and a police doctor pronounced the deceased dead at 10:10 am.[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 came into possession of sufficient Fentanyl to give him a blood level of 60 mcg, which was approximately 15 to 20 times the fatal average dose, which was proved to be fatal according to this particular laboratory… Again, I end by saying I am so very sorry you lost your son and that you have not got all the answers you would like to have. I suspect we shall probably, however much you burrow; I suspect one will not find a complete answer as to how he came to have 60 mcg per litre of Fentanyl in his bloodstream at post-mortem. It is difficult to explain it on the basis of at most three patches on the evidence I have heard, unless he had secured a supply from some other source that we do not know about and for which there is no evidence left in the flat after his death when the police went to enquire.”[8]Both before and since the inquest the claimant has devoted herself to finding out how her son came to die as he did, with the object of ensuring that any lessons that may be learned from the circumstances of his death are learned, and of preventing any avoidable deaths in the future. Furthermore since the inquest she has made complaints that have resulted in investigations into a number of aspects of the case. The most wide ranging was that carried out by the Croydon NHS Primary Care Trust (Croydon PCT). Its terms of reference were to – “Review the evidence related to – concerns about the quality of care provided by the GP and OOH doctors. The safety of controlled drug (CD) prescribing by the GP and OOH doctors. concerns about the quality of care provided by the GP and OOH doctors. The safety of controlled drug (CD) prescribing by the GP and OOH doctors. Review the response of NHS Direct to phone calls from DJ.” Review the OOH policies and procedures related to - CD prescribing. responding to complaints. investigating significant events. Assess the quality of medical records of doctors who prescribe CDs. Review the accuracy of information provided to the coroner by the GP. Investigate any other areas identified as relevant to this investigation.”[9]The report of the investigation was issued on 26 September 2008. It contains a comprehensive analysis of the facts leading to the death of the deceased, and its conclusions were summarised in the following terms – “This complex incident has its roots in deficiencies in the management of DJ by different doctors working in several organisations. The investigation has highlighted failures in relation to doctors' knowledge of controlled drug prescribing and consultation skills. It has also identified how the doctors' perceptions of their OOH responsibilities affected their management of this patient. In addition, there were system failures which related to controlled drug prescribing, identifying, auditing, and investigating significant events and SUIs, and in relation to new patient record reviews and repeat prescribing. Patient factors also contributed to the way DJ was managed by the doctors.”[10]The report made a series of detailed recommendations to doctors, to the out of hours service, to the GP practice, to the Croydon PCT, to the British National Formulary “to revise the data on fentanyl to include all relevant warnings”, and to the Medicine and Healthcare Products Regulatory Agency (MHRA) “to review the reports related to fentanyl associated deaths and to consider issuing an alert”.[11]It appears that the recommendations to the British National Formulary and to the MHRA were the result of the claimant having brought to the attention of the investigating team a drug warning issued in June 2005 by Janssen LP, the US manufacturers of fentanyl, following a review of 120 fatalities linked to unintentional overdoses of fentanyl, and an Information Alert to healthcare professionals issued in July 2005 by the US Food and Drug Administration (FDA) in relation to the risk of unintended overdose and death associated with the use of fentanyl transdermal patches. In the Information Alert issued by the FDA it was noted, inter alia, that a patient using a fentanyl patch may have a sudden and possibly dangerous rise in their body level of fentanyl, or have a more potent fentanyl effect if they use other sedating medicines, drink alcohol, have an increase in body temperature or are exposed to heat, or if they use other medicines which increase the elimination half-life of fentanyl. The FDA recommended that fentanyl patches should always be prescribed at the lowest dose needed for pain relief, that they should not be used to treat short-term pain, or pain that is not constant, and they should only be used by opioid tolerant patients who are already taking other narcotic analgesics, and who have chronic pain that is not well controlled with shorter-acting analgesics.[12]It is also to be noted that at the time of the Croydon PCT investigation, the MHRA had received 36 fatal reports associated with fentanyl, and in 30 of such cases fentanyl was the sole suspect drug.[13]The claimant also complained to the Royal Pharmaceutical Society of Great Britain as to the dispensing of fentanyl by Miss Shinali Patel and Mr Kirifkumar Patel, the pharmacists at Sefgrove Pharmacy who had dispensed the prescriptions on 29 and 30 December 2005. The Society's Investigating Committee did not refer the complaint to the Disciplinary Committee, but issued a ‘letter of advice’ to each of the pharmacists.[14]Thirdly the claimant complained to the GMC as to the involvement of Dr Virdi, alleging that he had provided substandard clinical care, kept inadequate records, and given inaccurate information to the inquest. The GMC's case examiners concluded that there was no realistic prospect of establishing that Dr Virdi’s fitness to practice was sufficiently impaired to justify action on registration; and in consequence by letter dated 7 October 2008, the GMC informed the claimant that it had decided to take no further action on the complaint, a position that was maintained following further correspondence with the claimant and a review of the case.[15]Fourthly there was an internal investigation by NHS Direct which identified procedural issues relating to the failure to identify frequent callers, and training needs for the individual health and nurse advisers who had handled the deceased's repeated calls on 30 December 2005. The investigation was subject to a National Peer Review in July 2006, which recommended action to improve the service, both at local and national level.[16]The claim The claimant contends that by reason of insufficiency of the enquiry and of the new evidence which is now available, it is necessary and desirable in the interests of justice that another inquest be held. There are two limbs to the argument advanced on her behalf. First it is submitted that the inquest failed to discharge its primary function of investigating fully ‘by what means’ the deceased came by his death. Mr Nicholas Brown, who appeared for the claimant, argues that the defendant ought to have investigated how the deceased came to have such an extremely high concentration of fentanyl in his blood and urine, and in particular whether it is possible that such a high concentration could have been attributable to the use of the fentanyl patches that he had been prescribed. He further submits that if a full and proper investigation had been undertaken, there was at least the possibility of a different verdict, namely a verdict of accidental death rather than an open verdict. This limb of the argument raises the question of the proper scope of the inquest.[17]Secondly it is submitted that there is a wider public interest in fully investigating how the deceased came to die from fentanyl toxicity in the light of the evidence that there have been a considerable number of deaths both in the USA and in the UK, that have been linked to unintended overdoses of fentanyl. Mr Brown argues that on the information now available, there is reason to suspect that the death of the deceased occurred in circumstances the continuance or possible recurrence of which is prejudicial to the health and safety of the public or of a section of the public.[18]The legal framework Section 13 of the 1988 Act provides, in so far as is relevant to this application, that – “(1) This section applies where, on an application by or under the authority of the Attorney-General, the High Court is satisfied as respects a coroner (“the coroner concerned”) either –(a) …(b) where an inquest has been held by him, that (whether by reason of fraud, rejection of evidence, irregularity of proceedings, insufficiency of inquiry, the discovery of newfacts or evidence or otherwise) itis necessary or desirable in the interests of justice that another inquest should be held. (2) The High Court many – (a) order an inquest, or as the case may be, another inquest to be held into the death either – (i) by the coroner concerned; or (ii) by the coroner for another district in the same administrative area; (b) order the coroner concerned to pay such costs of and incidental to the application as to the court may appear just; and(c) where an inquest has been held, quash the inquisition on that inquest. (3) …” (a) … (b) where an inquest has been held by him, that (whether by reason of fraud, rejection of evidence, irregularity of proceedings, insufficiency of inquiry, the discovery of newfacts or evidence or otherwise) itis necessary or desirable in the interests of justice that another inquest should be held. (a) order an inquest, or as the case may be, another inquest to be held into the death either – (i) by the coroner concerned; or (ii) by the coroner for another district in the same administrative area; (b) order the coroner concerned to pay such costs of and incidental to the application as to the court may appear just; and (c) where an inquest has been held, quash the inquisition on that inquest. As Moses LJ observed in R (on the application of Sutovic) v HM Coroner for Northern District of Greater London and Sutovic v HM Coroner for Northern District of Greater London [2006] EWHC 1095 (Admin) – “The power contained in section 13(1)(b) is stated in very broad terms. The necessity or desirability of another inquest may arise by reasons of one of the listed matters or “otherwise”. Notwithstanding the width of the statutory words, its exercise by the courts shows that the factors of central importance are an assessment of the possibility (as opposed to the probability) of a different verdict, the shortcomings in the original inquest, and the need to investigate matters raised by new evidence which had not been investigated at the inquest: see Re Rapier [1988] 1 QB 26, 34-35, 37H-38A, 39 per Woolf LJ and Simon Brown J; R v HM Coroner, Lincoln, ex p Hay. 19 February 1987; R v HM Coroner, Coventry, ex p O’Reilly. Times Law Reports, 3 April 1996; and R v Assistant Deputy Coroner for Northern District of London, ex p Bloom [2004] EWHC 3071 (Admin)… “[19]Section 11 (5) sets out the scope of an inquest - (5) An inquisition(a) …(b) shall set out, so far as such particulars have been proved – (i) who the deceased was; and (ii) how, when and where the deceased came by his death; and(c) …” And rule 36 of the Coroners Rules 1984 (the 1984 Rules) provides that: “(1) The proceedings and evidence at an inquest shall be directed solely to ascertain the following matters, namely: (a) who the deceased was; (b) how, when and where the deceased came by his death; (c) the particulars for the time being required by the Registration Act to be registered concerning the death. (2) Neither the coroner nor the jury shall express any conclusion or in any other matters.” (a) … (b) shall set out, so far as such particulars have been proved – (i) who the deceased was; and (ii) how, when and where the deceased came by his death; and (c) …” (a) who the deceased was; (b) how, when and where the deceased came by his death; (c) the particulars for the time being required by the Registration Act to be registered concerning the death.[20]In R v HM Coroner for North Humberside & Scunthorpe, ex parte Jamieson [1995] QB 1, Sir Thomas Bingham MR reviewed the relevant statutory and judicial authority as to the scope of an inquest under the 1988 Act and the 1984 Rules. He concluded his review by setting out fourteen general conclusions. Three are of particular relevance. “(2) Both in s.11 (5)(b)(ii) of the Act of 1988 and in Rule 36 (1)(b) of the Rules of 1984, “how”, is to be understood as meaning “by what means”. It is noteworthy that the task is not to ascertain how the deceased died, which might raise general and far-reaching issues, but “how…the deceased came by his death”, a more limited question directed to the means by which the deceased came by his death. (13) It is for the coroner alone to make reports with a view to preventing the recurrence of a fatality, that is the effect of Rules 36 (2) and 43. (14) It is the duty of the coroner as the public official responsible for the conduct of inquests, whether he is sitting with a jury or without, to ensure that the relevant facts are fully, fairly and fearlessly investigated. He is bound to recognise the acute public concern rightly aroused where deaths occur in custody. He must ensure that the relevant facts are exposed to public scrutiny, particularly if there is evidence of foul play, abuse or inhumanity. He fails in his duty if his investigation is superficial, slipshod or perfunctory. But the responsibility is his. He must set the bounds of the inquiry. He must rule on the procedure to be followed. His decisions, like those of any other judicial officer, must be respected unless and until they are varied or overruled.”[21]In R (Middleton) v West Somerset Coroner & anr [2004] 2 AC 182, the House of Lords addressed the issue of the scope of an inquest in circumstances in which Article 2 of the ECHR is engaged, and held that in such cases a change of interpretation of the 1988 Act and 1984 Rules was necessary for there to be compliance with the State’s obligations expressed in the convention. Such a change required a broader interpretation of “how” to denote “by what means and in what circumstances.” We are not here concerned with what has come to be known as a Middleton inquest; but in R v HM Coroner for Inner West London, ex parte Dallaglio [1995] 4 All ER 139, Sir Thomas Bingham MR gave further guidance as to the scope of a ‘judicial’ inquest at p.164. “Secondly, I wish to reject the argument advanced for the coroner that the applicants should not be granted relief since resumption of the inquests, if ordered, could lead to no useful result. The basis of this argument, founded on the recent decision of this Court in R v HM Coroner for North Humberside & Scunthorpe, ex parte Jamieson [1994] 3 WLR 82, was that the inquests could only investigate how the deceased came by their deaths, to which the only proper answer would be, as is already known, that they died by drowning following the collision between the Marchioness and the Bowbelle. Jamieson’s case was specifically directed to the verdict of lack of care in the context of deaths in custody, but the Court’s ruling was of wider application and it is true that if these inquests were to be resumed, the verdicts which the coroner could properly leave open to the jury at the end would be both limited and predictable. The Court did not, however, rule that the investigation into the means by which the deceased came by his death should be limited to the last link in the chain of causation. That would not be consistent with the Court’s conclusion (14), which emphasised the need for a full, fair and fearless investigation and the exposure of relevant facts to public scrutiny, and it would defeat the purpose of holding an inquest at all if the inquiry were to be circumscribed in the manner suggested. It is for the coroner conducting an inquest to decide, on the facts of the given case, at what point the chain of causation becomes too remote to form a proper part of his investigation.” See also R (on the application of Catherine Smith)v Assistant Deputy Coroner forOxfordshire [2009] EWCA Civ 441, [2009] 3 WLR 1099 at paragraph 82.[22]It is also to be noted in this context that s.8 (3) of the Act provides that:
“If it appears to a coroner, either before he proceeds to hold an inquest or in the course of an inquest begun without a jury, that there is reason to suspect: (a) (…) (b) (…) (c) (…); or (d) that the death occurred in circumstances, the continuance or possible occurrence of which is prejudicial to the health or safety of the public or any section of the public, he shall proceed to summon a jury in the manner required by subsection (2) above.” (a) (…) (c) (…); or (d) that the death occurred in circumstances, the continuance or possible occurrence of which is prejudicial to the health or safety of the public or any section of the public, he shall proceed to summon a jury in the manner required by subsection (2) above.”
[23]In his judgment in Dallaglio, Simon Brown LJ expressly approved the observation of Morland J in R v HM Coroner for Western District of East Sussex, ex parte Homberg [1994] 158 JP 357 at 381:
“… Rule 36 should not be interpreted as to defeat the purpose of s.8 (3)(d)… if ‘the proceedings and evidence’ are narrowly confined, the answers to the ‘how’ question will not serve the purpose of the section, the prevention or reduction of the risk of future injuries in similar circumstances.”
[24]It is clear that the Defendant took a narrow view of the scope of the inquest. He was satisfied that his duty to address the question of how the deceased came by his death was discharged by establishing that it was due to a fatal dose of fentanyl. As he said at paragraph 15 of his witness statement served in response to the application:
“In circumstances where the scope of the inquest is limited to determining “by what means”
David came by his death, the findings of Dr Seet and in particular, that the direct cause of death was Fentanyl toxicity (with pneumonia having a contributory effect) were sufficient to answer that question. … As mentioned in (1) above, the function of the inquest was to establish “by what means” David came by his death. This is answered by Fentanyl. Who prescribed it, or increased it, and in what dose, are not relevant.”[25]But as Sir Thomas Bingham MR, as he then was, observed in Dallaglio, an investigation into the means by which the deceased came by his death will not necessarily be limited to the last link in the chain of causation. It will be for the coroner to determine how far down the chain it is necessary for him to investigate, but his discretion is subject to his duty to carry out a “full, fair and fearless investigation”.[26]The questions left unanswered as a consequence of the scope of the inquest being limited to investigation of the immediate cause of death of the deceased, were identified in paragraph 36 of the Particular of Claim:
“1. The defendant failed to investigate how the deceased came to have a post-mortem concentration of 60 mcg/l Fentanyl in his blood and a post-mortem concentration of 580 mcg/l in his urine... when on the evidence presented to him, the expected range of concentration in Fentanyl in blood after the application of a 100mcg/hr transdermal patch was 1.9 - 3.8 and the average Fentanyl concentrations in 4 adults who died from excessive use of transdermal fentanyl was 23mcg/l (range 12 -- 41) in blood and 233mcg/l (range 89 -- 449) in urine. The defendant did not call expert evidence from a toxicologist. The defendant did not seek appropriate expert evidence from a toxicologist. The defendant did not seek or call evidence from the US manufacturers of Fentanyl or the UK distributors. The defendant did not seek or adduce any appropriate evidence about Fentanyl or its potential complications beyond the expected range of concentration of Fentanyl in blood after the application of a Fentanyl transdermal patch or the expected fatal dose. 2. The defendant did not investigate how the deceased first came to be prescribed Fentanyl transdermal patches in December 2005 or how his prescription came to be increased from 50mcg/hr patches to 100mcg/hr patches. The defendant did not hear evidence from the doctors who prescribed this medication to the deceased. The defendant did not call these witnesses to give evidence. 3. The defendant did not fully investigate how the deceased came to be given a second prescription for 72 hour 100mcg/hr Fentanyl transdermal patches within 24 hours of the first such prescription being collected. ” 4. The defendant did not investigate the beliefs, knowledge and practices of all the individual doctors who prescribed medication to the deceased between 23 December 2005 and 30 December 2005, or the contact which the deceased had with NHS Direct during this period fully or at all. 5. The defendant did not investigate any possible system deficiencies related to the policies and procedures of the different health care providers. The defendant did not seek or call any relevant evidence in relation to these issues. 6. The defendant did not investigate the information which was or might have been available to the prescribing doctors or other healthcare care staff with whom the deceased came into contact between 23 December 2005 and 30 December 2005 about the use of Fentanyl and the potential complications. 7. The defendant did not investigate when the deceased first suffered symptoms of Fentanyl toxicity, what those initial symptoms were, or how the deceased's condition probably deteriorated until he died. The defendant did not call appropriate expert evidence from a toxicologist in relation to these issues.”
[27]In my judgment there is substance to the argument advanced on behalf of the claimant that there was an insufficiency of enquiry. The defendant identified the central question, namely how the deceased came to have such a high concentration of fentanyl in his blood, but failed to investigate the answer to it, apparently on the basis that it could not be answered, save by making the assumption that the deceased had somehow come into possession of an additional supply of fentanyl transdermal patches from some other and unknown source. But as was forcefully submitted on behalf of the claimant, there was no evidential basis for such an assumption.[28]I consider that a full and proper investigation of the means by which the deceased met his death would have involved investigating in particular whether the quantity of fentanyl prescribed and apparently used by the deceased could have been fatal in certain circumstances, and if so whether such circumstances were present. It would also have involved consideration of whether the concentration of fentanyl in samples of blood and urine taken at post mortem on 3 January 2006, 3 days after death, was a reliable indication of the concentration in the blood stream at the time of death. The investigation of such questions would have required evidence from a toxicologist. If the quantity of fentanyl prescribed could of itself have been fatal in certain circumstances, then it would have been necessary to enquire as to how it came about that the deceased was first prescribed fentanyl transdermal patches on 25 December 2005, to have been given a repeat prescription at twice the dose on the following day, with a further repeat prescription at twice the original dose by Dr Virdi on 30 December.[29]I recognise that my conclusion is informed to some degree by the information about fentanyl now before this court. It may well be that had the defendant been aware of it, he would have appreciated that at the least it might be possible to answer the central question, namely how the defendant came to have such a high concentration of fentanyl in his blood, and in consequence to have taken a different view as to the scope of the inquiry. But I am satisfied that the first limb of the claimant’s argument is well founded, and that there was an insufficiency of inquiry. I am also satisfied that there is the possibility of a different conclusion, namely a conclusion of accidental death, if a further inquest is held.[30]As to the second limb of the claimant’s case, I consider that in the light of the information now available as to the incidence of death by unintended overdose of fentanyl, there is a wider public interest in a full inquiry into the means by which the deceased came to meet his death. Such an inquiry would address a number of issues of wider public interest. In particular there is an issue as to degree to which the medical profession at large is alive to the possible danger to life presented by the prescription of fentanyl. Secondly the circumstances in which the deceased came to be given repeat prescriptions of fentanyl over a very short period of time, apparently on demand, and in the case of the prescriptions issued by the out of hours GP services, without reference to the deceased’s medical records, are of obvious public concern. Such issues were addressed in the investigation undertaken by the Croydon PCT, but that investigation was not conducted in public. In the course of the hearing we sought further information as to the distribution of the ‘Serious Untoward Incident’ report produced by the investigating team. A response to that request was subsequently received from the Croydon PCT by letter dated 15 March 2010. The report has been circulated to each of the Out of Hours organisations involved in the incident, Croydoc, Seldoc and Emdoc, to the prescribing doctors, to NHS Direct, the editor of the British National Formulary and to the Medicine and Healthcare Products Regulatory Agency. But it is not in the public domain. It is also to be noted that in the letter of 15 March 2010, the Assistant Medical Director of NHS Croydon commented under the heading ‘Fentanyl Deaths’ that:
“In December 07 there were 36 deaths attributable to fentanyl. As of February 2010 the Medicine and Healthcare Regulatory Agency statistics show that in the last 12 months, there have been 76 fentanyl related deaths. The findings of inquests are vital to understanding the factors that contribute to such a significant increase in fentanyl related deaths. There is a continuing need to alert doctors to the indications for prescribing this drug, its contraindications and drug interactions, side effects and safe prescribing procedures.”
[31]I am satisfied that it is necessary in the interests of justice that another inquest be held. The scope of that inquest will be for the presiding coroner to determine. It would also appear, although that too would be a matter for the coroner, that the further inquest should be held with a jury.[32]I would therefore quash the inquisition and order that a further inquest be held.[33]I agree.

Cited in 1 later judgment