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Investigation and inquest
On 8th May 2012 I commenced an investigation into the death of Susan Edea Poore. The investigation concluded at the end of the inquest on 18th March 2014. The conclusion of the inquest was "Mrs Poore stepped in front of a train and suffered fatal injuries. At the time Mrs Poore was taking anti-depressant medication." The medical cause of death was “Multiple Trauma due to collision with a train”.
Circumstances of the death
On 3 May 2012, Mrs Poore's family reported to local Police that she was missing. During that morning a train driver saw a person standing on the line near Thains Lane, East Runton. He reports that he sounded his horn but the person did not move. Despite applying his brakes the train did not stop quickly enough and struck the person causing fatal injuries. The person was later identified as Mrs Poore. Mrs Poore had recently been prescribed anti-depressant medication.
Coroner’s concerns
(1) Shortly before her death, Mrs Poore had been prescribed anti-depressant medication (Mirtazapine 29.03.2012 changed to Fluoxetine 23.04.2012)
(2) The evidence is that her depression deteriorated following her taking the anti-depressant medication and the mode of death was out of character for Mrs Poore
(3) Although the medication did contain a message warning of the potential side-effect of worsening depression, this did not prevent Mrs Poore’s death
Information checked against the published report and official responses