Danielle Monique Christina JONES · Prevention of Future Deaths report

On 14/05/25 I commenced an investigation into the death of Danielle Monique Christina JONES. The investigation concluded at the end of the inquest on 1/10/25.

The medical cause for the death of Danielle Jones was as follows;

1a Multidrug Toxicity
II History of Depression, Drug Abuse

The conclusion at inquest was Suicide.

On 13/5/25 Miss Danielle JONES was found unresponsive at her home address and confirmed as deceased by attending paramedics. She was found in the bathroom by her partner. Miss Jones had a background of mental health problems, substance misuse, previous and recent (prescription) drug overdose.

Post-mortem toxicology tests found evidence of High levels of amitriptyline along with excess zopiclone and recent substantial cocaine use. The Pathologist concluded she died from multi drug toxicity.

The amitriptyline level was within the fatal range. The level of zopiclone was well above that expected from therapeutic dosage.

I found she died from the combined toxic effects of a fatal level of amitriptyline along with an excessive amount of zopiclone.

1. Miss Jones had a background of substance abuse, previous and recent (prescription) overdose. Miss Jones self-disclosed overdose of GP prescribed Diazepam on 12th July 2023, 18th April 2024, and 13th June 2024. Miss Jones also reported depleted GP prescribed Zopiclone medication on 4th September 2024.
2. She had a telephone consultation with her GP on 24/2/25 where she disclosed an overdose of her prescription medication and had a further telephone appointment with her GP on 25/2/24 where she repeated the same information.
3. Miss Jones was being supported by Cranstoun Drug & Alcohol Service. Miss Jones attended for an appointment with Cranstoun on 21/2/25 where she confirmed that a recent tablet ingestion was a deliberate overdose attempt. Following that appointment the substance abuse nurse updated the GP practice via email GP updated via email correspondence of well-being concern following intentional overdose. It is unknown whether this communication was known to the GP who spoke to Miss Jones on 24th and 25th February 2025.
4. In any event, Miss Jones self-reported to her GP on both 24/2/25 and 25/2/25 that she had taken an excessive amount of her prescription medication 3 weeks previously. She reported that she had taken ████████ but vomited afterwards.
5. Although Miss Jones was signposted to Mental Health Services by her GP, her prescription medications do not appear to have been reviewed and the GP surgery continued to prescribed repeat medications in large amounts at 28 day frequency without any further review subsequent to her appointment on 25/2/25.
6. She was issued with repeat prescriptions on 3 occasions subsequent to her appointment on 24th and 25th February 2025 when she self-closed an overdose of prescription medication.
7. On 6/3/25 despite a recent self-reported admitted overdose of prescription medication of ████████
████████
████████ Miss Jones was prescribed
8. On 27/3/25 despite a recent self-reported admitted overdose of prescription medication of ████████
████████ Miss Jones was prescribed
Amitriptyline ████████ Diazepam ████████ lamotrigine ████████
mirtazapine ████████ pregabalin ████████ zopiclone
9. On 28/4/25 despite a recent self-reported admitted overdose of prescription medication of ████████
████████████████████████████████████████ Miss Jones was prescribed ████████
████████████████████████████████████████████████████████████████████████
████████████████████████████████████████████████████████████████████████
10. Miss Jones died on 13/5/25 from the combined toxic effects of a fatal level of amitriptyline along with an excessive amount of zopiclone.
11. The clinical lead at Cranstoun had previously had discussions with the GP about reducing Miss Jones prescription for zopiclone.
12. No medication review appears to have taken place after Miss Jones self-reported overdose of prescribed medication nor after concerns were raised by Cranstoun.
13. GMC Guidance requires a practitioner to prescribe drugs or treatment including repeat prescriptions, only when they have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs and to keep clear, accurate and legible records, reporting the relevant clinical findings, the decisions made.
14. There is no clinical rationale recorded for the continued prescribing of Miss Jones’s repeat medications in terms of managing Miss Jones’s risk of overdose given her recent disclosure e.g. reducing the frequency to 7 days rather than 28 days.
15. There is no evidence of any medication review having taken place after Miss Jones’s disclosure of overdose of prescription medication or prior to her repeat prescriptions being issued on 6/2/25, 27/3/25 or 28/4/25. Her last reported medication review was on 23/8/24.