Viktor John Anthony Scott-Brown · Prevention of Future Deaths report

On 20th December 2018 I commenced an investigation into the death of Viktor John Anthony SCOTT-BROWN aged 23. The investigation concluded at the end of the inquest on 12th August 2020. The conclusion of the inquest was that the death was a suicide. The medically certified cause of death was:-

I a Hanging

Viktor John Anthony Scott-Brown was found hanging at his home address overnight on the 14th/15th December 2018 and pronounced dead at the scene. There were no suspicious circumstances. He had recently been prescribed Lamotrigine but had not been warned that use of that medication carries a risk of causing thoughts of self harm or suicide, and his taking of that medication was not monitored accordingly. Had he been informed of that risk, he would have sought medical assistance when he began to experience thoughts of self harm and suicide, and it is unlikely he would have taken his life when he did.

Mr Scott-Brown was prescribed Lamotrigine by an NHS Foundation Trust Consultant Psychiatrist. The prescribing consultant did not give Mr Scott-Brown a Trust information sheet about Lamotrigine and a Patient Information Leaflet about Lamotrigine from the drug manufacturer, GlaxoSmithKline. It was common ground that the consultant should have done so. Both documents record as a side effect of using Lamotrigine a risk that the patient may begin to experience thoughts of self-harm or suicide. Mr Scott-Brown was never given that information.

The consultant gave evidence that he was not aware of that particular side effect of Lamotrigine, and that his prescribing practice was informed by the British National Formulary and The Maudsley Prescribing Guidelines. Neither the online BNF viewable via the NICE website nor the 10th Edition of The Maudsley Guidelines (to which the court was referred) refer to that side effect in their respective entries for Lamotrigine.

Subsequent to the conclusion of the Inquest, I have learned from the Oxleas NHS Foundation Trust that when Mr Scott-Brown was prescribed Lamotrigine, then the current edition of the Maudsley Guidelines was the 13th Edition. The Inquest heard no evidence about the 13th Edition of the Maudsley Guidelines and information therein concerning Lamotrigine.

Quite apart from any issue regarding the consultant’s knowledge about Lamotrigine (and the existence of the 13th Edition of the Maudsley Guidelines) and his not having given Mr Scott-Brown the Trust’s prepared information about the drug and its side effects, I am concerned that two obviously reputable sources of pharmacological information are apparently silent, or have been silent, on a potentially significant side effect of this particular drug.

From a lay perspective, there is apparent potential for harm to patients depending upon which resources a prescriber consults before prescribing Lamotrigine. That potential for harm might be ameliorated were the advice about Lamotrigine consistent across all such resources.