Gary Ash
15 May 2024 · Coroner Nadia Persaud · East London
The coroner's concerns
1. inappropriate off licence use of Dantrolene
“Management of the condition neuroleptic malignant syndrome, including the inappropriate, off licence, use of Dantrolene”
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”