Current requirements to dispense the antipsychotic drug Clopixol (oral zuclopenthixol dihydrochloride) as a 'special container' product should be reviewed, a coroner has told the MHRA and GPhC as he reported on the suicide of a 51-year-old man in Sunderland.

In a prevention of future deaths report dated March 12, assistant coroner for Sunderland David Place said Jason Brown died at his home address on September 6 2022 by taking an overdose of his prescribed medication.

An inquest into Mr Brown’s death made a finding of suicide, with the medical cause of death attributed to cardiac arrhythmia as well as the overdose.

Clopixol is indicated for the treatment of psychoses, particularly schizophrenia. Mr Brown had received a full pack of tablets from his pharmacy “only 17 days before taking an overdose of this medication,” the coroner said, noting that the pharmacy had “confirmed in evidence that this had been dispensed in a full pack in accordance with its special container status”. Medicines are granted special container status when it is judged that it is not practical to split a pack, for example if the product is sterile or hygroscopic. 

The coroner appears to have redacted the pack size and/or the tablet strength from his report in a number of places. Community Pharmacy England’s special container database shows entries for three Clopixol products – 10mg, 25mg and 2mg tablets – each of which are available in pack sizes of 100.

Mr Place added: “The pharmacy also confirmed that another patient at the practice received the same medication in a seven-day monitored dosage system (MDS) but could not confirm whether the remaining pack was then disposed of for that patient.”

Mr Place said he was “concerned” that the original pack dispensing rules for Clopixol “can endanger the safety of a patient with a history of suicidal risk and previous overdose attempts”.

“In my opinion there is a risk that future deaths will occur unless action is taken,” said Mr Place, adding: “Deaths may be prevented if the original pack dispensing guidance was reviewed for this medication.”

In addition to regulators the GPhC and MHRA, the report was sent to manufacturer Lundbeck and the National Pharmacy Association. All parties are required to respond to the coroner before May 8 and either provide “details of action taken or proposed to be taken” or “explain why no action is proposed”.

Sunderland pharmacies Demnox Pharmacy and Herdman Pharmacy are named as interested persons in the report and have received a copy of it, as have their solicitors and counsel. Local surgery Silksworth Medical Practice and its legal counsel have also been sent a copy, as have Mr Brown’s family and the Care Quality Commission.