William Green

I am Heath Westerman, H.M. Assistant Coroner, for the coroner area of Shropshire, Telford & Wrekin.

On 12 July 2023 Mr Ellery, H.M. Senior Coroner for Shropshire, Telford & Wrekin commenced an investigation into the death of William Stephen GREEN The investigation concluded at the end of the inquest on 27 February 2025 The conclusion of the inquest was: William Stephen Green died on 9 July 2023 at The Royal Shrewsbury Hospital, Mytton Oak Road,  Shrewsbury, Shropshire. He died as the result of toxic epidermal necrolysis secondary to Lamotrigine. This is a rare but recognised complication arising from taking Lamotrigine which was  prescribed to Mr Green for the required treatment of his then known symptoms from 5 June 2023 until its cessation on or around 8 July 2023. Those complications, however, were not counselled or  alerted to Mr Green upon his discharge from the hospital on 7 June 2023, nor was he advised on what to look out for and what to do in such circumstances. His death was contributed to by alcohol  dependent disease.

Mr Green was admitted to The Royal Shrewsbury Hospital, Mytton Oak Road, Shrewsbury,  Shropshire on 5 June 2023 following a seizure probably alcohol related. He was started on  Lamotrigine an anti-epileptic at a dose of 25mg once daily. He was discharged on 7 June 2023 with a pack of 56 Lamotrigine tablets at a dose of 25mg to be taken one daily. His compliance with taking  the Lamotrigine once in the community is not known. He was re-admitted to The Royal Shrewbury Hospital on 5 July 2023 following a collapse and with a rash on his chest, back and upper limbs. He  was treated for sepsis secondary to viral meningitis. A treatment plan was followed which included  Lamotrigine to be administered once daily at the rate of 25mg. His condition deteriorated and on 8  July 2023 he was diagnosed with Steven Johnstone Syndrome. He died on 9 July 2023 as the result of toxic epidermal necrolysis secondary to Lamotrigine. Contributing to his death was alcohol dependent disease.

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. – (1) Once any patient at The Royal Shrewsbury Hospital is initiated on a new prescribed drug during  an admission, no written record is ever made anywhere by anyone including pharmacy; nurses;  doctors or consultants explaining or counselling the patient upon the possible side-effects or  complications as a result of taking a specific prescribed drug; nor is there any written record on what  to look out for and what to do in such circumstances and where they can get assistance. (2) No provision seems to be in place to record what should happen when the patient lacks capacity  to understand such an explanation even when it is offered.

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