Viktor Scott-Brown
18 Aug 2020 · Coroner Oliver Longstaff · County Durham and Darlington
The coroner's concerns
1. lack of patient information leaflet on Lamotrigine risk of self-harm
“The prescribing consultant did not give Mr [name redacted] a Trust information sheet about Lamotrigine and a Patient Information Leaflet about Lamotrigine from the drug manufacturer, GlaxoSmithKline”
2. absence of self-harm risk disclosure to patient
“Had he been informed of that risk, he would have sought medical assistance when he began to experience thoughts of self harm and suicide”
3. inconsistent pharmacological guidance sources
“potential for harm to patients depending upon which resources a prescriber consults before prescribing Lamotrigine”
Responses
2020-0163-Response-from-Oxleas-NHS-Foundation-Trust.pdf ↗· Oxleas NHS Foundation Trust
2020-0163-Response-from-BNF-Publications_Redacted.pdf ↗· Informa Healthcare
Stated action
“we will add a side-effect of suicidal ideation to the lamotrigine monograph in the BNF. We will also add information on this side-effect to the important safety section of the lamotrigine monograph.”
2020-0163-Response-from-NICE_Redacted.pdf ↗· Informa Healthcare
2020-0163-Response-from-Tees-Esk-and-Wear-Valleys-NHS-Foundation-Trust_Redacted-1.pdf ↗· Esk and Wear Valley NHS Trust