Danielle Jones
27 Oct 2025 · Coroner Joanne Lees · The Black Country
The coroner's concerns
1. substance abuse and recent overdose
“Miss [name redacted] had a background of substance abuse, previous and recent (prescription) overdose. Miss [name redacted] self-disclosed overuse of GP prescribed Diazepam on 12th July 2023, 18th April 2024, and 13th June 2024. Miss [name redacted] also reported depleted GP prescribed Zopiclone medication on 4th September 2024.”
2. overdose disclosure to GP
“She had a telephone consultation with her GP on 24/2/25 where she disclosed an overdose of her prescription medication and had a further telephone appointment with her GP on 25/2/24 where she repeated the same information.”
3. lack of communication between Cranstoun and GP
“Miss [name redacted] was being supported by Cranstoun Drug & Alcohol Service. Miss [name redacted] attended for an appointment with Cranstoun on 21/2/25 where she confirmed that a recent tablet ingestion was a deliberate overdose attempt. Following that appointment the substance abuse nurse updated the GP practice via email GP updated via email correspondence of well-being concern following intentional overdose. It is unknown whether this communication was known to the GP who spoke to Miss [name redacted] on 24th and 25th February”
4. unreviewed repeat prescribing after overdose disclosure
“She was issued with repeat prescriptions on 3 occasions subsequent to her appointment on 24th and 25th February 2025 when she self-disclosed an overdose of prescription medication.”
5. continued prescribing after overdose disclosure
“On 6/3/25 despite a recent self-reported admitted overdose of prescription medication of [REDACTED]”
6. polypharmacy after overdose disclosure
“On 27/3/25 despite a recent self-reported admitted overdose of prescription medication of Miss [name redacted] was prescribed Amitriptyline [REDACTED], Diazepam [REDACTED], lamotrigine [REDACTED], mirtazapine [REDACTED], pregabalin [REDACTED], zopiclone [REDACTED].”