The opioid antidote naxolone is viewed as key to preventing deaths from substances like nitazenes, but was detected in just one in every seven inquest records.
In January 2025, the coroner reviewing the death of Joe Black raised concerns, external naloxone was only available to take home from some substance misuse services and many people who used drugs were also not engaging with them.
Joe, who had schizophrenia and substance misuse disorder, was found dead aged 39 from an overdose including heroin adulterated with nitazenes at a hostel in Camden, London.
Neither the hostel nor the mental health NHS Trust which were treating Joe were permitted to give naloxone kits to their residents or patients who were known to use drugs.
In December, the Department of Health and Social Care began a 10-week consultation, external on proposed legislative changes to expand naloxone access in the UK.
His mother Jude said: “Joe was a wonderful, sensitive, caring, intelligent, talented young man. And he, like everybody else, had a right to live.
“He also was carrying this terrible illness and coping as best he could, and was hugely vulnerable to exploitation and accidental overdose.”
She said it was “negligent” it had taken nearly a year since the inquest for the consultation to begin.
“I feel it diminishes the value of my son’s life and the tragedy of his death.
“People like Joe are still hugely at risk and I’m sure they’re still dying.”