“Cyclizine During the course of the Inquest a number of issues pertaining to cyclizine…”

The coroner’s concerns

1. Cyclizine During the course of the Inquest a number of issues pertaining to cyclizine were raised. In considering these it is important to note that cyclizine is not tested for in routine toxicology testing so the prevelance of cyclizine abuse is not well understood. Many professionals who gave evidence had not worked with a patient with such an addiction previously. It was clear throughout the hearing that the knowledge of cyclizine varied amongst many professionals as to how it was prescribed and obtained. Medicines and Healthcare Products Regulatory Authority The court heard evidence that intravenous cyclizne is by prescription only but oral cyclizine can be purchased over the counter at a pharmacy. In order to purchase oral cyclizine in a pharmacy a pharmacist should seek information as to why it is required and should be present. Charlene's family gave evidence that following Charlene's death they had been able to obtain cyclizine in a pharmacy directly from a pharmacy assistant with no questions being asked of them. Chair of the Faculty of Eating Disorders Royal College of Psychiatrists The court was made aware of the research conducted in 2009 as published in the journal PNS, "Proceedings of the Nutrition Society", "Cyclizine dependence in patients with complex nutritional requirements" Thursby-Pelham, De Silva, Stroud and Fine, 23 July 2009. This identified cyclizine dependence in four female patients who all had complex nutritional problems. Whilst it is acknowledged that this is one study and as stated cyclizine addiction is rare, it was not something which had been considered before Charlene's addiction by the Eating Disorder Service. For the Manchester Eating Disorder Service there is now a greater awareness of cyclizine. This may be important nationally given its use as an anti-emetic. NHS England Cyclizine is not a controlled drug. At one stage consideration was given to using the Controlled Drugs local intelligence network as convened by NHS England (Controlled Drugs (Supervision and Management of Use) Regulations 2013) to put an alert out to local pharmacies to warn them about Charlene's purchasing of cyclizine. From the evidence there was a lack of clarity and understanding from professionals as to whether this local network could be used for drugs which are not controlled drugs. The fact that the legislation refers to controlled drugs may mean there is a lack of understanding about using this for system for non controlled drugs such as cyclizine. 2. Commissioned Pathway in Greater Manchester for the taking of bloods in community patients who are compromised. Greater Manchester Integrated Care Board During the course of the evidence the court heard evidence from the GP who was responsible for obtaining weekly bloods to monitor her eating disorder. There is no commissioned pathway in Rochdale for GPs to refer patients who require bloods but who are compromised and therefore hard to obtain blood from. As a result patients are attending A&E departments for these to be taken. w

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, 2023-0516

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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