Zulfiqar HUSSAIN · Prevention of Future Deaths report

On 18 July 2023 an investigation into the death of Zulfiqar HUSSAIN was commenced. The investigation concluded at the end of the inquest on 12 October 2023. The conclusion of the inquest was drug related and the cause of death was:

1a Combined drug toxicity

1b -

1c -

II Bronchopneumonia

Zulfiqar Hussain was 48 years old at the time of his death. He suffered with mental health issues and was receiving mental health care from the community mental health team. He was also a chronic illicit substance user and had received regular support from Turning Point.

On 2 April 2023, the deceased was found at his home address having died from combined drug toxicity leading to significant respiratory depression, which was compounded by the presence of pneumonia. It was not possible, on the evidence available, to determine whether the deceased had ingested the drugs with the intention of ending his life.

During the course of the inquest, the Court heard evidence about correspondence sent to the GP practice by Turning Point and the Mental Health Team. An adverse medication marker should have been prominently placed on the deceased’s electronic medical records as a result of correspondence from Turning Point. However, this was not done.

There were at least 2 occasions when correspondence from the mental health team should have prompted a clinical review by a clinician. These did not take place and the Court heard that this was most likely because the correspondence was filed by administration staff without it having been seen by a clinician.

Whilst the evidence does not reach the requisite standard to show that the deceased’s death would have been averted had correspondence been reviewed by clinicians at the GP practice, it meant that opportunities to provide the deceased with support and care and to foster his engagement with health services were missed.

It is regrettable that this Court has previously issued a Regulation 28 report to your practice on the lack of robust processes to ensure clinician review of correspondence and, despite assurances, the situation in which correspondence is filed by administration staff without any clinician review pertains (see Regulation 28 report dated 23 December 2021).

(1) As previously raised in Report to Prevent Future Deaths dated 23 December 2021, incoming correspondence to the GP practice continues to be dealt with by administrative staff who decide whether or not it is placed before a GP. The concern is that there is no robust system in place to ensure that communication to the surgery which may require action to be taken by medical staff is brought to their attention.

(2) Adverse medication markers are not being placed on computerised medical records and this creates the risk that contraindicated medications may be inadvertently prescribed.