Frances Newbury

I am:   Coroner Melanie Sarah Lee Assistant Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP

On 9 June 2023 an investigation was commenced into the death of Frances Ann Newbury aged 61 years. The investigation concluded at the end of the inquest on 10 November 2023. The medical cause of death was 1a. Acute polydrug toxicity ([REDACTED]); 1b. substance misuse disorder;

1. chronic lung disease.

The conclusion of the inquest was drug related.

Frances Newbury was found unconscious and not breathing by her partner on the morning of 20 May 2023 at their home address. London Ambulance Service was called at 09:04 and arrived at 09:09. Ms Newbury’s partner reported to the attending paramedics that she had taken [REDACTED] at approximately 21:00 the evening before. Ms Newbury had a long history of drug abuse,[REDACTED] . At post-mortem she was found to have ‘popping’ scars on the anterior and posterior aspects of both thighs and on both shins. Toxicology examination found [REDACTED] in her system. During ALS resuscitation attempts, paramedics inserted an igel, used a LUCAS2 device, inserted an intraosseous needle into her left tibial plateau and administered 10 doses of adrenaline, sodium chloride and intravenous glucose.

During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. Despite paramedics being informed that Ms Newbury had taken illicit drugs the previous evening (albeit the report being of [REDACTED]) and obvious signs of ‘popping’ scars on her legs from [REDACTED], Naloxone was not administered. Although in Ms Newbury’s case, it would have made no difference, I am concerned that in another case it may. This is not the first inquest in which I have queried why Naloxone has not been administered to patients (with a opiate misuse history) when all other potential reversible causes have been treated.

In my opinion, action should be taken to prevent future deaths and I believe that your organisation has the power to take such action.