A coroner’s court has given the Government and NHS England until February 27 to set out how they intend to prevent drug-related deaths after an inquest found a man who died from an overdose was not given naloxone.

Joseph Benjamin Forbes Black, 39, was found dead at his home in August 2023 from acute polydrug toxicity after taking heroin that had been mixed with protonitazene and metonitazene.

A report by Inner North London’s assistant coroner Ian Potter concluded the presence of nitazenes, a type of synthetic opioid, “more than minimally contributed to his death.”

Potter’s report said staff at the supported accommodation where Forbes Black lived and the mental health Trust treating him were not permitted to provide naloxone kits “to known drug users.”

Potter said Forbes Black, who “had a longstanding history of harmful substance misuse” and suffered from schizophrenia, was engaging well with his treatment for the condition “and his mental health was considered stable in the time leading up to his death.”

However, he “repeatedly declined to engage” with substance misuse treatment even though he was warned about the risks of nitazenes in heroin by a mental health nurse who was treating his schizophrenia.

Potter’s report said staff at his accommodation had access to naloxone which “they could administer to residents if (they) came across a situation in which the administration was indicated.”

However, Forbes Black was not given naloxone because “the circumstances in which he was found did not indicate that the administration of naloxone would be of any use in this instance.”

The report added: “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.”

Potter said “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.”

However, he also concluded that drug users would need to get naloxone “from a local substance misuse service” if they wanted it but expressed concern that “naloxone is most easily accessed through the very service(s) that many drug users are not engaged with.”

“This is not a localised matter and is more likely a nationwide issue and action should be taken more widely,” Potter said.

Warning the “need for action is heightened by the increased incidence of heroin having been adulterated with nitazenes,” he urged the DHSC and NHSE to outline the “details of action taken or proposed to be taken, setting out the timetable for action” and explain why if no action is proposed.