Joseph Forbes Black
2 Jan 2025 · Coroner Ian Potter · Inner North London
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. unavailability of naloxone kits to drug users
“The MATTER OF CONCERN is, as follows:”
2. delayed naloxone administration
“I am concerned that this set of circumstances raises the risk of future deaths occurring because the provision of naloxone kits could be made more widely available to those most likely to need them”
3. synthetic opioid adulteration in heroin
“the increased incidence of heroin having been adulterated with 'nitazenes' (particularly potent synthetic opioid drugs), which increases the risk of drug users unwittingly overdosing”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“all staff including non-health care staff and operational/security staff should have training in recognising and responding to opiate overdose including using available Naloxone.”
This report
“I am concerned that this set of circumstances raises the risk of future deaths occurring because the provision of naloxone kits could be made more widely available to those most likely to need them.”