“S are as follows: 1”

The coroner’s concerns

S are as follows: 1. There does not appear to be any national guidance available to psychiatrists and mental health practitioners dealing with possible cases. Those involved in James’ care made insufficient effort to research or evaluate the potential risks and consequences of James obtaining and using the to end his life and any information that was obtained from brief internet searches was not disseminated to colleagues beyond those immediately involved in James’ case only. I am concerned that there is a risk of future fatalities if mental health practitioners do not have ready access to timely and up-to-date information about the risks associated with sodium nitrate/nitrite. 2. The family raised concerns about the risks of in suicides as part of the Serious Incident Review undertaken by the Trust but this section was omitted from the final report at the direction of the SIR review panel. This meant that there was a missed opportunity for the Trust to reflect on lessons that may properly be learned from James’ death, an omission which they now appear to be taking steps to remedy. However, I am concerned that there is a risk of future fatalities at a national level if Mental Health Trusts are not using Serious Incident Reviews and other internal investigations to learn lessons from suicide cases, including about the risks presented by sodium nitrate/nitrite. 3. The inquest heard evidence from a senior Accident & Emergency doctor about the information available from the National Poisons Information Service to emergency departments who encounter patients who have ingested . This included information about the potential availability of an antidote, ‘methylene blue’. However, there is apparently no national guidance about the appropriate use of the antidote in cases involving cardiac arrest and whether attempts should be made to administer it in such cases. I am concerned that there is a risk of future fatalities if A&E clinicians do not have access to comprehensive and up-to-date information about toxic substances and their possible antidotes to know when – and when not – to administer treatment. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 23 September 202123 September 2021. I, the coroner, may extend the period.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2021-0260

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0