Michael Vince

27 Jun 2022 · Coroner Graeme Irvine · East London

The coroner's concerns

1. long term use of medication
“The NICE guidelines for indicate that it is a suitable medication for the short term treatment of insomnia, it advises against prolonged use due to risk of tolerance and withdrawal symptoms. Mr [name redacted] is said to have been prescribed for 20 years.”
2. lack of meaningful review of prescription
“No evidence exists to support that Mr [name redacted] GP or community mental health team meaningfully reviewed his prescription”
3. lack of shared dependence evidence
“Evidence of Mr [name redacted] 's dependence upon was not shared by his GP with the mental health trust”
4. unmonitored PRN administration
“The frequency with wh ich Mr [name redacted] was administering his PRN was never monitored”