Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0292, written 1 Jul 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Jul 2014 |
|---|---|
| Reference | 2014-0292 |
| Deceased | Sindy Woodhall |
| Coroner | Lisa Hashmi |
| Coroner area | Manchester North |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 4 |
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REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Head of Trading Standards, Oldham Metropolitan Borough Council 2. Trading Standards Institute 3. Department for Business, Innovation & Skills (Consumer Safety) 4. Chief Executive, Public Health England CORONER | am Assistant Coroner for the coroner area of Manchester North CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroner's and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 INVESTIGATION and INQUEST On the 29" October 2013 | commenced an investigation into the death of Sindy Louise Woodhall. CIRCUMSTANCES OF DEATH The deceased had long standing addictions to alcohol and Butane and Propane and was known to misuse the latter gases on an extremely regular basis. On the 24" October 2013, the deceased was found in a collapsed state, in the street near to her home, by a passer-by. Ms Woodhall was taken fo hospital but subsequently died. Post mortem examination and toxicology confirmed the medical cause of death to be 1a) Butane and Propane inhalation Toxicity. 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 inquest, it transpired that cans of the aforementioned gases were being sold to the deceased by local retailers who were fully aware of her addition/problems. Whilst morally reprehensible, there was no law to prevent them from selling large amounts of the toxic/potentially fatal gases to the deceased. 2. Lack of regulation. No powers afforded to Trading Standards to take action/prosecute. Risk to public health. ACTION SHOULD BE TAKEN YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely the 27" August 2014, |,thecoroner,mayextendtheperiod. = 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 namely the deceased's next of kin and the Senior Investigating Officer, Greater Manchester Police. | am also under a duty fo send the Chief Coroner a copy of your response, The Chief Coroner may publish either or both in a complete or redacted or summary from. 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. Date: 1 July 2014 eS
4 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
From Rt Hon Norman Lamb MP Minister of State for Care and Support | Department Department of Health i of Health Richmond House 79 Whitehall London SW1A 2NS Mrs L Hashmi ; Assistant Coroner 10 er A AAK HM Coroner's Court The Phoenix Centre Church Street 10 SEP 2014 Heywood OL101LR ). ar Py Hamed, Thank you for your letter following the inquest into the death of Sindy Woodhall. In your report you state that the medical cause of death was from Butane and Propane inhalation toxicity. The deceased had long standing addictions to alcohol, Butane and Propane and was known to misuse these gases on a regular basis. On the 24 October 2013, the deceased was found in a collapsed state on the street near her home, by a passer- by. She was taken to hospital but subsequently died. | was sorry to read of Ms Woodhall’s death and wish to extend my sincere sympathies to her family. You raise the following matters of concern: e During the course of the inquest, it transpired that cans of the aforementioned gases were being sold to the deceased by local retailers who were fully aware of her addition/problems. Whilst morally reprehensible, there was no law to prevent them from selling large amounts of the toxic/potentially fatal gases to the deceased. e Lack of regulation. e No powers afforded to Trading Standards to take action/prosecute. e Risk to public health. | note that you sent your report to the Chief Executive of Public Health England (PHE). Please be advised that PHE is an executive agency of the Department of Health. | am aware that the Chief Executive of PHE, Duncan Selbie, has already responded to you directly about the concerns you raise in this Regulation 28 report. oe) Department of Health | have attached the PHE response for completeness. | fully support the views and advice given in this response and have nothing further to add. | hope that this response is helpful and | am grateful to you for bringing the circumstances of Ms Woodhall’s death to my attention. NORMAN LAMB —_— Public Health England Duncan Selbie Chief Executive Wellington House 133-155. Waterloo Road : London SE1 8UG > ; Tel: 020.7654 8090 www.gov.uk/phe Mrs Ld Hashmi : 5 August 2014 Assistant Coroner Greater Manchester North HM Coroner's Court The Phoenix Centre L/Cpl Stephen Shaw MC Way Heywood OL10 1LR Dear Mrs Hashmi . Sindy Louise Woodhall Deceased — Date of Birth 13.08.1969 — Date of Death 23.10.2013 Thank you for sending your regulation 28 notice following the inquest into the sad death of Ms Woodhall. We share your concern about abuse of volatile substances (VSA) such as butane and propane and have been working with the Department of Health to support their efforts to restrict inappropriate access to these products. A large number of retailers already restrict access to butane lighter refills and some have committed to restricting the sale of multiple canisters in one transaction. The Association of Convenience Stores (ACS) was asked by the public health minister last year to urge its members to remove accessible displays and restrict sales to one can per customer. ACS reassured the minister that its members already had policies in place to Testrict access to butane. We understand that Oldham’s new service specification for provision of specialist treatment of substance misuse makes clear that the new service should cover all substances, including volatile ones. The lacal Alcohol and Drugs Strategic Forum, chaired by the local authority's Director. of Public Health and attended by the Head of Trading Standards/Licensing, is looking at closer working with retailers on this matter and will consider the issue at its next meeting. We have recently refined the information we collect on VSA as part of the National Drug Treatment Monitoring System in line with recommendations from Re-Soly, the national charity dedicated to the prevention of VSA, in part to add Propane to the data collected routinely on people presenting with butane abuse.
Date: 21 July 2014 Our ref: JG Your ref: a os yh Be WE Oldham Council Mrs L J Hashmi Neighbourhoods Directorate HM Coroner’s Court Trading Standards & Licensing Team The Phoenix Centre Sir Robert Peacock House, L/Cpl Stephen Shaw Way Vulcan Street, Oldham, OL1 4LA Heywood Tel: 0161 770 4730 OL10 1LR Fax: 0161 770 4481 Dear Madam Sindy Louise Woodhall, deceased dob 13.8.69 | write further to your letter of 1 July 2014 enclosing a copy of your Regulation 28 notice in relation to the above deceased person. The Council was very sorry to note the death of Sindy under such circumstances. As outlined in your notice your concerns were around the lack of regulation or powers afforded to Trading Standards to take any action against a retailer who, in full knowledge of the addition in this matter, still sold products to her. Whilst it is an offence to sell to a child there are no other powers that we have to take any action. There is also no licensing regime in place to register or licence traders of such products, other than alcohol, and therefore we do not know who sells it. | shall certainly ensure that the trader concemed is visited and spoken to by my Officers on the safety/health implications and the moral obligations in relation to those who suffer from addictions as well as a reminder about sales to minors of age restricted products in general. | trust the letter you have written to the Department for Business, Innovation and Skills may prompt them to consider legislating in this area. Yours faithfully Trading Standards & Licensing Manager Direct line: Email: many players... one team www.oldham.gov.uk
me Public Health England Duncan Selbie Chief Executive Wellington House 133-155 Waterloo Road London SE1 8UG Tel: 020 7654 8090 www.gov.uk/phe Mrs LJ Hashmi 5 August 2014 Assistant Coroner Greater Manchester North HM Coroner's Court The Phoenix Centre L/Cpl Stephen Shaw MC Way Heywood OL10 1LR Dear Mrs Hashmi Sindy Louise Woodhall Deceased — Date of Birth 13.08.1969 — Date of Death 23.10.2013 Thank you for sending your regulation 28 notice following the inquest into the sad death of Ms Woodhall. We share your concern about abuse of volatile substances (VSA) such as butane and propane and have been working with the Department of Health to support their efforts to restrict inappropriate access to these products. A large number of retailers already restrict access to butane lighter refills and some have committed to restricting the sale of multiple canisters in one transaction. The Association of Convenience Stores (ACS) was asked by the public health minister last year to urge its members to remove accessible displays and restrict sales to one can per customer. ACS reassured the minister that its members already had policies in place to restrict access to butane. We understand that Oldham’s new service specification for provision of specialist treatment of substance misuse makes clear that the new service should cover all substances, including volatile ones. The local Alcohol and Drugs Strategic Forum, chaired by the local authority's Director of Public Health and attended by the Head of Trading Standards/Licensing, is looking at closer working with retailers on this matter and will consider the issue at its next meeting. We have recently refined the information we collect on VSA as part of the National Drug Treatment Monitoring System in line with recommendations from Re-Solv, the national charity dedicated to the prevention of VSA, in part to add propane to the data collected routinely on people presenting with butane abuse. kg | Public Health England We are also looking to improve the national collection of drug-related (including VSA) mortality data from coroners so that action can be taken at a national and local level. | hope this is helpful but please do contact me should you wish to discuss the matter further. Chief Executive c National Director of Health Protection and Medical Director EE Director of Drugs and Alcohol
ding standards 0 PA to the Chief Executive/ Cc “r | [ L J ra Executive Support Manager ! } i) cd & Le Cc Trading Standards Institute 1 Sylvan Court, Sylvan Way Southfields Business Park Basildon, Essex, $S15 6TH Telephone, Fax: E-Mail: Mrs LJ Hashmi ee Assistant Coroner Se Greater Manchester North > HM Coroner's Court y The Phoenix Centre L/Cpl Stephen Shaw MC Way Heywood OL10 1LR 10 July 2014 Dear Mrs Hashmi Sindy Louise Woodhall, deceased — DOB 13.8.1969, DOD 24.10.2013 Thank you for your letter of 1 July 2014 following the conclusion of the inquest re Sindy Woodhall. | would like to take this opportunity to advise you that the Trading Standards Institute is a private company and professional body for trading standards officers, as such this matter is not something that we are able to get involved with as we have no powers, this would be a matter for trading standards departments that are run by local authorities. On a separate matter you may be interested to hear that TS! has recently conducted a workforce survey of trading standards services in England and Wales. This demonstrates the severe and deep cuts to trading standards services which in turn has led to a reduction in activity and prioritisation. A copy of the survey can be viewed at : www.tradingstandards.gov.uk/policy/WorkforceSurvey2014.cfm. 1am sorry that our organisation is not able to be of any further assistance in this matter. Yours sincerely PA to a eas; B tne Executive Support Manager The Trading Standards Institute is a company limited by Guarantee. Registered in England and Wales. Register Number 38769. Registered office: 4 a) INVESTORS Sy 2 IN PEOPLE ” Sounfiels Busines Park www. tradingstandards. gov.uk Basitdon, Essex SS15 6TH Certificate No. FS 570376 VAT Reg. No GB 795 8626 60
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