‘Death drug’ claimed victim
He said: “It’s clear that prior to his death that he had taken fatal quantities of ocfentanil and diazepam which was not prescribed. The diazepam would have added to its potency. Combined together it brought about his death.”
He said that although numerous health professionals had done their very best to help him there had been, with hindsight, a “lost opportunity” in failing to offer him the chance to refer himself to the drugs and alcohol advisory service though he acknowledged: “We don’t know whether he would have co-operated.”
Of the “extremely dangerous” drug, ocfentanil, he said anyone using it was taking part in a kind of “Russian roulette”. Mr Fleming added: “There’s a good, good, almost a racing certainty that they are not going to wake up again.”
His conclusion was that Mr Johnson, who he remarked was “incredibly bright” and “had everything to live for”, had died from a drugrelated death and said he had not found “any evidence that he intended to take his own life. He mistook the toxicity of the fatal dose.”
Medical investigator Dr Manouri Senaratne, who contributed to a serious incident report for South West Yorkshire Partnership NHS Foundation Trust, said two lessons had been learned from her investigation.
These included improving communications between medics, and where healthcare professionals could not get access to patients, ensuring that they contact their next of kin.
After the hearing, Mark’s mum Lynn said: “I would just like to try to convey how amazingly special he was. He saw the world in a totally different way from the rest of us. His friends and family still struggle to come to terms with someone as bright and special as Mark not being around.
“Life was just too difficult for him and his anxiety overwhelmed him. It was only in the past few months or so that he had started to self-medicate and look obsessively at what was wrong with him to try and help himself.
“On his profile on Facebook his friends’ and colleagues’ comments give an idea of the caring, funny, talented man he was. He’d always have a pack of Trivial Pursuit cards with him.
“We will miss him every single day for the rest of our lives and would urge anyone struggling with mental health or drugs to seek help. Don’t give up.”