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recurance

Gary Ash

15 May 2024 · Coroner Nadia Persaud · East London

The coroner's concerns

  1. 1. inappropriate off licence use of Dantrolene

    “Management of the condition neuroleptic malignant syndrome, including the inappropriate, off licence, use of Dantrolene”
  2. 2. lack of knowledge around diagnosis of serotonin syndrome

    “The lack of knowledge around the diagnosis of serotonin syndrome and the risk of it developing following the combined use of Fentanyl and Ondansetron as part of anaesthesia”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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