“The inquest heard evidence that the potential dangers of the combination of…”
Dated 4 Mar 2025, from the coroner for Hampshire, Portsmouth and Southampton. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 29 Apr 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated4 Mar 2025
- Deadline29 Apr 2025
- Published on judiciary.uk7 Mar 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| National Institute for Health and Care Excellence | Response publishedPublished on judiciary.uk in March 2025. |
| Royal College of Physicians | Response publishedPublished on judiciary.uk in March 2025. |
The coroner’s concerns
– The inquest heard evidence that the potential dangers of the combination of amitriptyline, paroxetine and ivabradine is not widely appreciated and does not trigger an alert on the prescribing software used in primary care or by pharmacists. The potential dangers related to a failure to metabolise amitriptyline which can, incrementally, lead to toxicity. I am also concerned that those prescribing ivabradine should have a full understanding of the potential interaction with amitriptyline and paroxetine.
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, 2025-0121
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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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
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