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Investigation and inquest
On 10/01/2018 I commenced an investigation into the death of Abdeslam BENELGHAZI. The investigation concluded at the end of the inquest on 9th October 2019.
The medical cause of death: 1a) combined effects of methadone, zuclopenthixol, gabapentin, clonazepam.
The conclusion of the inquest was: Accident contributed to by neglect with a narrative which stated “As the jury, we conclude that the inappropriate prescribing of combined medications alongside the failure to adequately monitor and escalate concerns significantly contributed to the death of Abdeslam Benelghazi”
Circumstances of the death
The deceased, known as Abde throughout the inquest was a patient detained under Section 2 of the Mental Health Act.
The medical diagnosis for Abde being schizophrenia co-existing with mood changes known as schizo-affective disorder. This was treated with the anti-psychotic zuclopenthixol and mood stabilizer sodium valproate.
The deceased was also taking gabapentin for chronic neuropathic pain and methadone to moderate, treat and to cease his use of heroin. The last recorded time that Abde had methadone was 35mgs on 30th November 2017.
In addition he was prescribed clonazepam. This prescription was started when Abde was at the Cygnet Hospital in Weston (2nd – 7th December 2017) when he was not initially taking methadone. Consultant said clonazepam and diazepam were prescribed to help with withdrawal. He was given 20mgs of methadone at the Cygnet Hospital on 5th and 6th December.
When the deceased was transferred to The Long Fox Unit at Weston General Hospital on the 7th December 2017 his prescription of methadone was increased and the clonazepam remained. I attach a list of the medications prescribed and administered.
The jury found in that...
“the factors that contributed to his death include:
i) Increasing the dosage of methadone beyond the normal limits set out in recognised guidance:
ii) Continuing clonazepam, a drug known to be associated with an increased risk of death when taken in conjunction with opiates, without establishing the reason for the original prescription:
iii) Having taken the steps set out above, failing to put in place an adequate pharmacological care plan to assess, monitor and review the patient and to communicate it to relevant staff:
iv)Upon the patient presenting with signs of over sedation and/or reduced consciousness on at least three occasions in a 48 hour period, the failure of the medical and nursing team, notwithstanding the absence of a pharmacological care plan, to initiate any medical investigation or intervention including enhanced physical and/or non-contact observations. And furthermore the failure to administer naloxone”
Abde died on 9th December 2017.
Coroner’s concerns
An expert was instructed to assist in this case namely ████████ who practices in general adult psychiatry with a special interest in the psychiatry of addition.
He agreed with the medical cause of death, that the drugs Abde was prescribed specifically methadone with other sedative medications zuclopenthixol, gabapentin and clonazepam can cause a combined effect of central nervous system depression and respiratory depression increasing the risk of sudden death.
He expressed a particular concern in relation to the prescribing of clonazepam with methadone. The reasons he gave were that clonazepam has a long half life; side effects include respiratory depression; that one supplier of clonazepam states “concomitant use of clonazepam with opioids may result in sedation, respiratory depression, coma and death”; that clonazepam is a means of delivering a high equivalent dose benzodiazepine without exceeding BNF limits.
He said that in this case clonazepam may have been the drug that tipped the balance.
Information checked against the published report and official responses