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Investigation and inquest
On 31 January 2024 I commenced an investigation into the death of Neil Michael YATES aged 53. The investigation concluded at the end of the inquest on 01 November 2024. The conclusion of the inquest was that Neil died of a Drug Related Death. The cause of death being:
1a Mixed Drug Toxicity, Bronchopneumonia
II. Chronic Obstructive Pulmonary Disease, Cirrhosis
Circumstances of the death
Neil Michael Yates was a 53 year old gentleman who had a number of co-morbidities, including long QT syndrome. Neil also had a history of being a habitual heroin user. Whilst in the community Neil was prescribed MST (morphine sulphate tablets) instead of liquid morphine due to the risk of liquid morphine on his long QT syndrome. This was prescribed by a voluntary sector organisation specialising in substance misuse and criminal justice intervention projects in England and Wales. On being remanded into custody the GP records were reviewed by the prison GP, this medication change did not appear on his records and so liquid morphine was prescribed to him. This change did not cause or contribute to his death, however, during the inquest evidence was heard that when organisations, other than GPs, prescribe medications to individuals it takes a number of weeks before the information is sent to the GP surgery for it to be placed on the GP summary for that individual; thus posing a risk that further medication is prescribed to the patient without knowledge of what has already been prescribed.
Coroner’s concerns
The delay of information relating to what has been prescribed to an individual being sent to the GP surgery by voluntary and NHS organisations.
Information checked against the published report and official responses