Joseph Forbes Black

I am Ian Potter, assistant coroner for Inner North London.

On 17 August 2023, an investigation was commenced into the death of Joseph Benjamin FORBES BLACK, aged 39 years at the time of his death. The investigation concluded at the end of an inquest on 23 December 2024. The conclusion of the inquest was ‘drug-related death’. The medical cause of death was: 1a acute polydrug toxicity (heroin, cocaine, metonitazine, protonitazine) 1b substance misuse disorder II  mental health disorder

Joseph Forbes Black had a longstanding history of harmful substance misuse, against a backdrop of ‘unspecified schizophrenia’. He engaged well  with the treatment of his schizophrenia and his mental health was considered stable in the time leading up to his death. However, despite being aware of available help, support, and treatment in relation to substance misuse, Mr Forbes Black repeatedly declined to engage. On 9 August 2023, Mr Forbes Black was found deceased at his home address. He died as a result of acute polydrug toxicity, which included the  taking of heroin that had been adulterated with protonitazene and metonitazene. The presence of ‘nitazenes’ more than minimally contributed to his death.

During the course of my investigation and the inquest, the evidence revealed a matter giving rise to concern. In my opinion, there is a risk that future deaths could occur unless action is taken. In the circumstances it is my  statutory duty to report to you. The MATTER OF CONCERN is, as follows: For context, on 26 July 2023, the Office for Health Improvement & Disparities issued a ‘National Patient Safety Alert’ (Ref no.: NatPSA/2023/009/OHID) (‘the Alert’). The Alert was entitled ‘Potent synthetic opioids implicated in  heroin overdoses and deaths’ and it referred to known nationwide incidents of so-called ‘nitazenes’ having been found in batches of heroin. The Alert  required, certain healthcare providers, to raise awareness of the heightened  risks to anyone who may use drugs. There was clear evidence that the risks raised by the Alert were communicated to Mr Forbes Black within the timeframes required. They were communicated by a mental health nurse, who was treating Mr Forbes Black in relation to his schizophrenia. Naloxone, the ‘antidote’ for opioid overdoses, was not administered in Mr  Forbes Black case. This because the circumstances in which he was found  did not indicate that the administration of naloxone would be of any use in this instance. Staff at the supported accommodation where Mr Forbes Black lived, had naloxone that they could administer to residents if the staff came  across a situation in which the administration was indicated. The evidence revealed that, neither the supported accommodation provider nor the mental health NHS Trust that was treating Mr Forbes Black were permitted to give naloxone kits to their residents/patients who were known  drug users. In my experience, from this inquest and others, a significant proportion of  illicit drug users are not engaged with or decline to engage with substance  misuse services for a number of possible reasons. The evidence in the  inquest was that, if a drug-user wanted to have naloxone in their possession as a safety-net measure, they would need to obtain this from a local  substance misuse service. I am concerned that this set of circumstances raises the risk of future deaths occurring because the provision of naloxone kits could be made more widely available to those most likely to need them. The present situation appears to be that naloxone is most easily accessed through the very service(s) that many drug-users are not engaged with. My concern, based on the evidence  heard at this inquest and others that I am aware of, is that this is not a  localised matter and is more likely a nationwide issue and that action should  be taken more widely. It further seems to me that the need for action is heightened by the increased incidence of heroin having been adulterated with ‘nitazenes’ (particularly potent synthetic opioid drugs), which increases the risk of drug users  unwittingly overdosing.

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