Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0456, written 20 Oct 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Oct 2014 |
|---|---|
| Reference | 2014-0456 |
| Deceased | Samuel Duckworth |
| Coroner | Andrew Harris |
| Coroner area | London Inner (South) |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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 Re Samuel Duckworth, case ref 01545-14 THIS REPORT IS BEING SENT TO: The Secretary of State for Health, Rt. Hon Jeremy Hunt, Richmond House, 79 Whitehall, London SW1A 2NS 1 | CORONER | am Dr Andrew Harris, Senior Coroner, London Inner South 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 | INQUEST On 23rd July, | opened an inquest into the death of: Samuel Duckworth, aged 34 years, died 05.06.14 | concluded the inquest at a full hearing on 14th October 2014. The medical cause of death was Diazepam, Codeine and Alcohol intoxication. The court found that he died from a drug and alcohol related death. 4 | CIRCUMSTANCES OF THE DEATH The circumstances were recorded as: Mr Duckworth was found dead at 16.56 on 05/06/14 in his flat having taken an overdose of Diazepam, Codeine and alcohol. He was an anxious man with poor impulse control - and did not intend to take his life. The Diazepam was purchased on the internet. 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 MATTER OF CONCERN is as follows. — Mr Duckworth had consulted a Psychiatrist and offered help with alcohol withdrawal and psychological therapies for mood swings, anxiety and impulse control. He was only prescribed a small amount of Diazepam, which | infer is because of the risks of abuse. Yet he had no difficulty in purchasing these prescription only drugs on the internet, 20 empty packets being found at the scene. No evidence was admitted as to whether such access could be restricted or regulated. The ease of access clearly constitutes an on going risk to the lives of other vulnerable people, whose medication should be medically supervised. 6 ,; ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe that the Secretary of Sate may have or know who has the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10"" December 2014. |, the 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. If you require any fu i i i about the case, please contact the case officer, COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested | 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. [DATE] [SIGNED BY¥CORO 1 28 OckSbes do/4- Ae?
1 response 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.
separ Rt Hon Mike Penning MP Minister of State for Policing, Crime, Criminal Justice and Victims 2 Marsham Street, Home Office London SWiP 4DF www. gov. uk/home-office Andrew Harris H.M Area Coroner — London Inner South Inner South Coroner's Court 1 Tennis Street London 15 JUL 2015 SE1 7YD ~ Doe Andon INQUEST INTO THE DEATH OF SAMUEL DUCKWORTH — REGULATION 28 REPORT eee nae Thank you for your letter of 20 October 2014 to the Health Secretary about the tragic death of Samuel Duckworth from the combined toxic effects of diazepam, codeine and alcohol. Your letter was transferred to my Department on 26 June 2015, the department of health apologise for this delay. | am replying as the Minister for Policing, Crime and Criminal Justice and Victims with responsibility for drug policy. This is clearly a very tragic case and | am grateful to you for raising this issue with me. | note your request for action concerning the supply and importation of prescription only medicines by use of the internet The Government and law enforcement agencies take the issue of unlawful advertising and sales of drugs on the internet very seriously, and we continue to work with internet providers to ensure that they comply with the law. This can include closure of UK-based websites where they are found to be committing offences under the Misuse of Drugs Act 1971. Online purchasing remains a relatively small overall element of drug supply: the 2013/14 Crime Survey for England and Wales shows that just 1% of adults who used drugs in the last 12 months sourced them from the internet. The National Crime Agency (NCA), the police and the Medicines and Healthcare products Regulatory Agency routinely monitor controlled drugs and medicines being offered for sale on the internet and take action with industry partners to close websites trading illegally in these substances. Where it has been identified, or where there is reasonable suspicion to suggest, that controlled drugs or medicines containing controlled drugs are being sold on websites, law enforcement agencies have the relevant powers under the Misuse of Drugs Act 1971 to act against suppliers of controlled drugs, whether on controlled drug charges or on suspicion of wider drug-related offences. Considerable illegal activity takes place on the internet outside of UK jurisdiction. The UK continues to work with international partners to develop an effective response to the supply of controlled drugs and to react swiftly to emerging threats. In order to tackle illegally trading websites identified overseas, we are building strong partnerships with international partners. There is also ongoing work with the EU and other international regulatory agencies to ensure that, wherever possible, offending websites are amended to comply with the law. Rt Hon Mike Penning MP
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