Danielle Jones

.   Your Health Partnership Regis Medical Centre

I am Mrs Joanne Lees Area Coroner for the coroner area of The Black Country.

On 14/05/25 I commenced an investigation into the death of Danielle Monique Christina JONES . The investigation concluded at the end of the inquest on 1/10/25. The medical cause for the death of Danielle Jones was as follows; 1a Multidrug Toxicity II History of Depression, Drug Abuse The conclusion at inquest was Suicide.

On 13/5/25 Miss Danielle JONES was found unresponsive at her home address and confirmed as deceased by  attending paramedics. She was found in the bathroom by her partner. Miss Jones had a background of mental health problems, substance misuse, previous and recent (prescription) drug overdose. Post-mortem toxicology tests found evidence of High levels of amitriptyline along with excess zopiclone and recent substantial cocaine use. The Pathologist concluded she died from multi drug toxicity. The amitriptyline level was within the fatal range. The level of zopiclone was well above that expected from therapeutic dosage. I found she died from the combined toxic effects of a fatal level of amitriptyline along with an excessive amount of zopiclone.

During the course of the inquest the evidence revealed matters 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 MATTERS OF CONCERN are as follows.

1. Miss Jones had a background of substance abuse, previous and recent (prescription) overdose. Miss  Jones self-disclosed overuse of GP prescribed Diazepam on 12th July 2023, 18th April 2024, and 13th  June 2024. Miss Jones also reported depleted GP prescribed Zopiclone medication on 4th September 2024.
2. She had a telephone consultation with her GP on 24/2/25 where she disclosed an overdose of her prescription medication and had a further telephone appointment with her GP on 25/2/24 where she  repeated the same information.
3. Miss Jones was being supported by Cranstoun Drug & Alcohol Service. Miss Jones attended for an  appointment with Cranstoun on 21/2/25 where she confirmed that a recent tablet ingestion was a deliberate overdose attempt. Following that appointment the substance abuse nurse updated the GP  practice via email GP updated via email correspondence of well-being concern following intentional  overdose. It is unknown whether this communication was known to the GP who spoke to Miss Jones  on 24

th and 25 th February 2025.

In any event, Miss Jones self-reported to her GP on both 24/2/25 and 25/2/25 that she had taken an  excessive amount of her prescription medication 3 weeks previously. She reported that she had taken REDACTED] but vomited afterwards.

Although Miss Jones was signposted to Mental Health Services by her GP, her prescription medications do not appear to have been reviewed and the GP surgery continued to prescribed repeat medications  in large amounts at 28 day frequency without any further review subsequent to her appointment on  25/2/25.

She was issued with repeat prescriptions on 3 occasions subsequent to her appointment on 24 th and 25 th February 2025 when she self-disclosed an overdose of prescription medication.

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.