Prevention of Future Deaths reports · 2013

Christopher Scott

Regulation 28 report to prevent future deaths, reference 2013-0350, written 27 Nov 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report27 Nov 2013
Reference2013-0350
DeceasedChristopher Scott
CoronerDavid Ridley
Coroner areaWiltshire & Swindon
CategoryAlcohol, drug and medication related deaths
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

1. Rt Hon Theresa May MP
Home Secretary and Member of Parliament for Maidenhead
House of Commons
London
SW1A 0AA

1 | CORONER

lam David W G Ridley, Senior Coroner, for the Coroner area of Wiltshire & Swindon

2 | CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

3 | INVESTIGATION and INQUEST

On 25 July 2013 | commenced an investigation into the death of Christopher Michael
SCOTT aged 23 years at the time of his death. The investigation concluded at the end
of the inquest on 26 November 2013. The conclusion of the inquest was that
Christopher's death was drug related. | determined that Christopher died as a result of;

1a) Multiorgan failure and Bronchopneumonia
1b) Alpha methyltryptamine (AMT) toxicity.

4 | CIRCUMSTANCES OF THE DEATH

| determined that he took two pills containing the drug (AMT) on the evening of the 21"
July 2013 however | could not rule out that he did not take further pills containing the
drug the following day. Christopher was admitted to the Great Western Hospital in
Swindon early evening on the 22 July 2013, his condition further deteriorated and he
died on the afternoon on 24" July 2013 as a result of developing multiorgan failure and
bronchopneumonia both of which was attributable to the toxic effects of AMT.

5 | CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. —

(1) During the course of the evidence | read out a toxicology report that referred to other
deaths involving AMT. | exhibited 2 Internet research results that related to other AMT
deaths. Slightly unconventionally | exhibited these internet results as ‘C2’ and ‘C3’
(copies attached) to further support this report with a view to the prevention of future
deaths. The first report ‘C2’ referred to the death of Adam Weeks in November 2011.
His Inquest in March 2012 confirmed his death due to AMT intoxication and whilst the
report makes reference to the Coroner writing to appropriate authorities prior to
Christopher's inquest | did speak with that Coroner who indicated that he had not make

such a report (r43 report under the Coroners Rules 1984). Document ‘C3’ refers to
three other deaths in respect of which AMT appears to have been involved during 2012
and 2013. As it stands at the moment AMT is a “legal high” and | am concerned that as
it is currently a legal drug that it is readily available to be purchased for example over the
internet and in the community at large. The effects of AMT can vary from person to
person but clearly the effects can be deadly as the examples show including of course
Christopher's death.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you have the
power to take such action and | would be grateful if you could please review the position
insofar as AMT is concerned with a view to considering as to whether or not this drug
should become a controlled drug having regard to the provisions of the Misuse of Drugs
Act 1971 (as amended).

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 22 January 2014. |, the Senior Coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION

| have sent_a_copy of my report to the Chief Coroner and to the following Interested
Persons, AAR other & Father)

| am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest. You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.

27" November 2013

“ND ~Po

Senior Coroner for Wiltshire & Swindon

or 8

A CORONER is calling on authorities to ban AMT — a drug commonly used for recreational
use — following the death of a 21-year-old Gillingham man after a party.

Adam Weeks, of Loddon View, was out with friends at a pub in Stour Provost on November
19 last year when he collapsed and an ambulance was called, an inquest at Shepton Mallet
heard last week.

Mr Weeks was taken to Yeovil District Hospital but died the following day.

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East Somerset Coroner Tony Williams said there had been a history of recreational use of the
AMT drug since the 1960s, but this was the first death of its kind recorded in Dorset.

In recent years AMT had been widely promoted and was available to buy from websites —
and was not controlled under the Misuse of Drugs Act, said Mr Williams.

He said a report from Mr Weeks's GP confirmed that he had assured his social worker he was
working, had stopped taking drugs and was "taking control of his life".

But on n went out with friends to a party at Stour Provost and was seen taking
drugs. When the group went home he collapsed at Gillingham and an ambulance was called.
Police arrived and a nurse handed them a tablet which was found to be AMT.

Mr Williams said he had personally been in contact with police and given them full details
relating to Mr Weeks's death and the police were now "putting that information into their
system”.

He said he felt it was now appropriate for him as coroner to write to all of the appropriate
authorities, advising them to review their policy and consider adding AMT to their list of

illegal drugs.

Mr Williams recorded a verdict of accidental death.

Read more: http://www.thisissomerset.co.uk/Torch-carriers-miles-home/story-15588409-
detail/story.html#ixzz2INyTBAWM

Follow us: @thisissomnews on Twitter | thisissomerset on Facebook

Teenager dies in hospital after taking legal
high called AMT which he bought online

- Teenager's mother found him ‘in a bad way' in his
bedroom and dialled 999

- He was rushed into intensive care and placed in a
medically-induced coma

- But 17-year-old died in hospital yesterday after four
days in intensive care

- He is the third believed to have died in Hampshire as a
result of taking AMT

By Suzannah Hills

PUBLISHED: 17:18, 19 August 2013 | UPDATED: 17:19, 19 August 2013
.
°
:

30 shares

21

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comments

A 17-year-old boy has become the latest to die from taking the legal high
AMT after buying it online from Holland.

The teenager died yesterday morning following four days in intensive care at
Southampton General Hospital after consuming the drug known as alpha-
methyltryptamine (AMT).

The teenager’s mother found him 'in a bad way’ in his bedroom and dialled
999. He was rushed into intensive care and placed in a medically-induced
coma after swallowing the pill last Wednesday.

The boy, from Southampton, Hampshire, has not yet been named.

Tragedy: A 17-year-old boy placed in an induced coma for four days has died in hospital
after apparently taking a legal high he bought online

His death comes a little over a month after medical stud

19, died after apparently taking the drug while celebrating the end at his
university year.

More...

e 'The Troll Hunter': Mother-of-five spends six hours every night trawling internet to
expose online bullies

e Event rider, 26, dies after he is crushed by his horse during packed competition

e Novice explorer, 31, on his first Arctic expedition froze to death in 161mph
snowstorm which ripped his tent exposing him to -70C temperatures

Friends of the student, from Chandler's Ford, Hampshire, called 999 in the

early hours of the morning and he was taken to hospital, but doctors were
unable to save him.

AMT, which was originally produced as an anti-depressant, can be bought
online for just £30 a gram.

Doug Ferguson i
end of term

Users experience a state of euphoria and increased energy levels. But the
drug has devastating side effects, including paranoia and aggressive
behaviour..

Hampshire Police Detective Constable Jonathan Hyland warned people about
the consequences of taking legal highs.

He said: 'The clear issue is people who state they have a strong view about
not taking controlled drugs are importing and purchasing drugs they read on-
line are a substitute for controlled drugs.

"People incorrectly believe these "legal highs" are then both safe and
appropriate alternatives to street drugs.

‘Just because something is not illegal does not make it safe.

‘Unfortunately, it appears anyone can call anything a "legal high" and sell it
as "safe".

‘It only becomes clear it is not safe when someone becomes severely harmed
by taking it and subsequent investigations reveal substances within the
compound can be lethal.

‘This is the third exceptionally serious case involving AMT in Hampshire
since 2012.

‘If you are considering taking any type of non personally prescribed drug, I
would urge you to consider for a few minutes before you use the substance.

‘Think about how your family would feel, finding you in need of critical
medical attention.’

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Read more: http://www.dailymail.co.uk/news/article-2397167/Teenager-dies-hospital-taking-
legal-high-called-AMT-bought-online.html#ixzz2UScKzVZ

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