Michael Samuel Ian Anthony · Prevention of Future Deaths report

On 14.05.13 I opened an inquest into the death of Michael Anthony, aged 64, who died on 8th May 2013. The inquest was concluded on 26th March 2014. The conclusion of the inquest was given in a narrative:

Mr Anthony was found dead in his flat on 8th May 2013. There were no suspicious circumstances. He died from diabetic ketoacidotic coma. He had a very high Gabapentin level in his blood, which along with a fatty liver from Hepatitis B and/or diabetes, contributed to his death. It was not possible to conclude whether the ketoacidosis was also caused by a reaction to Gabapentin.

The Gabapentin level was five times normal therapeutic level. It was not determined why this level was so high. His ketonuria was reported by the toxicologist as either being due to diabetic coma (shortage of insulin) and/or a reaction to the drug Gabapentin. The toxicologist reported that Gabapentin was usually not prescribed in diabetics, as some individuals developed a severe reaction which precipitated diabetic coma. The court read the evidence of the GP, who did not refer to the reasons for prescribing Gabapentin and did not tell the consultant physician, but heard it was for pain relief. .

(1) It was not known whether Gabapentin was contraindicated to be prescribed in the deceased, who suffered severe Type 1 diabetes, or whether the prescribing doctors were aware of the rare side effect of Gabapentin in precipitating diabetic coma. If they were not there would be a potentially avoidable risk to other patients.