John Kirby
6 Dec 2018 · Coroner Veronica Hamilton-Deeley · Brighton and Hove
The coroner's concerns
1. delay in dealing with Mr Kirby
“The delay in dealing with Mr [name redacted] between August 2017 and March 2018.”
2. decision to prescribe Concerta without proper assessment
“am concerned about the decision to ask him to complete ADHD questionnaires and apparently suggest that he should be prescribed Concerta.”
3. failure to follow NICE Guidance in ADHD diagnosis and management
“am concerned that athouch a told me he had made a diagnosis of ADHD in October 2017 he did not follow the NICE Guidance, inform the GP, start prescribing, consider alternatives to prescribing, have a formal note made of the consultation with [the deceased] when the impact of this diagnosis was discussed with him or discuss the diagnosis with his immediate next of kin. On”
4. lack of alertness to suicide risk
“Even if Concerta had not been prescribed the GP letter and the information in the electronic records as to the A&E admission on the 4'"-5" April should have alerted the Trust to the information [the deceased] had given that he was suicidal and "wanted to die”
5. prescription without review
“Why was Mr [name redacted] prescribed Concerta without any (further) review?”
6. lack of proper monitoring
“Why was he not properly monitored as he should have been had the NICE Guidance been adhered too?”