A coroner has written the medicines regulator, NHS England and others following an inquest into the death of a patient due to cyclizine toxicity in January 2022.

Joanne Kearsley, senior coroner for Manchester North, raised concerns after investigating the death of 35-year-old Charlene Roberts at Fairfield General Hospital last year.

Charlene was described as an extremely complex patient who could be difficult to engage. She had a complex diagnosis of anorexia (since early 2000s), factitious disorder (2019) and cyclizine abuse (2019).

On the 10 January 2022 she attended A&E at Fairfield General hospital to have her weekly bloods taken. Following her death it was discovered she had left the ward on the 11 January 2022 and taken an uber taxi to a local pharmacy where she had purchased cyclizine.

Her cause of death following examination was found to be due to cyclizine toxicity.

The cornoner noted that cyclizine is not tested for in routine toxicology testing so the prevelance of cyclizine abuse is not well understood. She said it was clear throughout the hearing that the knowledge of cyclizine varied amongst many professionals as to how it was prescribed and obtained.

Intravenous cyclizine is available by prescription only but oral cyclizine can be purchased over the counter at a pharmacy. In order to purchase oral cyclizine in a pharmacy a pharmacist should seek information as to why it is required and should be present.

“Charlene’s family gave evidence that following her death they had been able to obtain cyclizine in a pharmacy directly from a pharmacy assistant with no questions being asked of them,” the coroner told the MHRA.

Coroners are required to raise concerns when they believe actions can be taken to prevent future deaths.