Nathan John COOKE · Prevention of Future Deaths report

On 1st March 2018 I commenced an investigation into the death of Nathan John COOKE, aged 36. The investigation concluded at the end of the inquest on 15th April 2019. The conclusion of the inquest was “Drug Related”.
The medical cause of death was found to be:
1a Cardio-Respiratory Failure
1b Severe Central Nervous System Depression
1c Methadone and Clomipramine Overdose
II

1) Nathan John COOKE was born on 4th January 1982. At the time of his death he was 36 years old and was unemployed.

2) Nathan John COOKE was found dead by his mother at 16.30 hours at his home address of ████████, Isle of Wight. He had last been seen by his mother when she had left the address that morning, but he was asleep at that point.

3) Mr COOKE had been prescribed a number of medications for his mental health and previous drug addiction issues, which included Methadone (an opiod drug which can be used for pain relief in some circumstances but is more commonly used as replacement therapy for heroin addiction or withdrawal) and Clomipramine (a tricyclic antidepressant drug where adverse reactions to excessive doses may cause cardiac arrhythmias, convulsions and central nervous system depression.)

4) Good practice dictates that when a patient is being prescribed Clomipramine, they should be monitored by ECG heart trace for the abnormal heart rhythm known as “QTc prolongation” which is a risk factor in sudden cardiac death.

5) Mr COOKE had been monitored in October 2017 and was found to have an abnormal reading with a QTc prolongation at 488 which could have been caused by the Methadone and Clomipramine. The guidance says that where there is a QTc of greater than 440, but less than 500, consideration should be given to reducing the dose of the medication or switching to a drug of lower effect, and repeating the ECG.

6) Mr COOKE and his mother were notified of this ECG concern, in particular the increased risk of potential heart arrhythmia and death.

7) Mr COOKE supplemented his prescription medication with illicit medication which had not been prescribed to him.

8) Mr COOKE was offered a number of appointments to attend for a further ECG – but he failed to attend them or declined to have the screen done when he attended for appointments. Efforts were made to reduce the dosage of the medication which he was being prescribed, with variable results.

9) It was acknowledged by the Drugs Worker who attended Court that it was important to convey to Mr COOKE (and other patients) that they absolutely needed to have a further ECG scan and review the results for patient safety. Whilst it was possible to decline to provide any further prescriptions to the patient to compel them to attend the surgery in order to obtain a prescription, this could be dangerous as it might precipitate them stopping their medication suddenly.

10) Whilst it is not believed that Mr COOKE suffered a fatal cardiac arrhythmia as a result of taking these medications, this was a risk factor which was not adequately addressed in his clinical management.

1. It was agreed that a more appropriate way to manage and control this situation whereby a patient is prescribed medication which could be dangerous to their welfare without regular monitoring would be for the primary care practice to write to the patient, inviting them to attend for a review, and informing them that if they failed to attend the review by a specified date, their medication would be reduced and eventually stopped. The incentive and responsibility to comply with clinicians is thereby passed to the patient.