Jacob Matthew WOODERSON · Prevention of Future Deaths report

On 29 August 2024, Senior Coroner Hassell, commenced an investigation into the death of Jacob Matthew WOODERSON (age 28 years). The investigation concluded at the end of the inquest on 23 May 2025. The conclusion of the inquest was that the medical cause of death was:
1a) Sudden arrhythmic death syndrome
2) Elvanse treatment for ADHD.

I returned the following narrative conclusion:
Jacob Wooderson was 28 years old. He was diagnosed by a privately instructed Consultant Psychiatrist as having ADHD (inattentive subtype presentation) in February 2024. He subsequently commenced Elvanse (Lisdexamfetamine) 30 mg. The dosage was increased to 50mg in June 2024 after an ECG, blood pressure, heart rate and other investigations were undertaken in accordance with national guidelines. In August 2024, Jacob increased his Elvanse dosage to 70mg. The blood pressure and heart rate information considered by his psychiatrist prior to prescribing 70mg Elvanse was previously submitted in June 2024 when Jacob was taking a 30 mg dosage. Following the increase to 70mg, Jacob reported problems with poor sleep and exhaustion to his friends. He collapsed and died at his home on 23 August 2024. The medical cause of his death was: 1a) sudden arrhythmic death syndrome; 2) Elvanse treatment for ADHD. The arrhythmia may have had a genetic cause or be linked to Jacob’s medication. It is not possible to establish the precise cause of the arrhythmia on the balance of probabilities from the evidence before me. Jacob Wooderson was not given any clear written advice from his psychiatrist regarding the side effects of Elvanse or the steps to be taken if any adverse side effects presented. This was a missed opportunity for Jacob to have information which may have led him to seek medical advice which could in turn have led to a different outcome.

In addition to the matters set out in the narrative conclusion, the evidence established that:

Jacob Wooderson had long standing issues around memory, concentration and focus which led him to seek an ADHD assessment and treatment, which included the prescribing of Elvanse.

The Toxicology evidence established that Elvanse (lisdexamfetamine) is a stimulant drug and that its use at any dose may result in cardiac effects including tachycardia, arrhythmias and potentially myocardial infarction. Increased heart rate and insomnia are consistent with the effects of amphetamine use even when taken therapeutically and particularly at the start of a new treatment (e.g. increased dosage) due to tolerance to that dose not being formed. The toxicologist’s view was that if there is evidence that a cardiac event had occurred, it is possible that this was enhanced by the use of amphetamine, even if taken therapeutically.

NICE guidance NG87 on the treatment and management of ADHD states at para 1.8.9 that where patients are prescribed medication for ADHD, prescribers should monitor heart rate and blood pressure and compare with the normal range for age before and after each dose change, and every 6 months.

Jacob had video consultations with his psychiatrist. The psychiatrist’s usual practice was to make handwritten notes during a consultation. These notes were then used to prepare a follow up letter to the patient. The handwritten notes of the consultation were then destroyed.

Jacob’s psychiatrist did not clearly document Jacob’s baseline blood pressure and heart rate prior to starting Elvanse or after increasing the dosage to 50 mg. Similarly, the advice given to Jacob regarding adverse side effects of Elvanse was not recorded at any point. It also appears that Jacob was not sent any follow up letter after his Elvanse dosage increased to 70 mg

Jacob increased his Elvanse dosage from 50 mg to 70 mg around 6 August 2024. Following that increase, he disclosed to his partner and friends that the 70 mg dosage of Elvanse made him “feel weird”, caused insomnia and led him to feel exhausted. The psychiatrist said that if they had known of Jacob’s symptoms on increasing the dosage to 70 mg, they would have advised him to stop taking Elvanse and reviewed his medication.

1) Elvanse is an amphetamine-based medication which can have fatal cardiac side effects. It is increasingly being prescribed in the NHS and in the private sector for ADHD symptoms. As the dosage of Elvanse may increase gradually over a period of months, there is the potential for a patient that has previously tolerated the medication to develop adverse side effects. Monitoring of heart rate and blood pressure may help identify serious side effects at an early stage.

2) Symptoms of ADHD can include forgetfulness and problems with inattention. Consequently, there is a risk that patients may not recall verbal advice regarding the adverse side effects of Elvanse, particularly if it is only given at the outset of treatment or is not followed up in writing.

3) The practice of remote consultations may mean that prescribers are reliant upon patients providing heart rate and blood pressure data outside of the consultation. Consequently, there is the potential for clinical decisions to be based on unreliable observations.