Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0112, written 20 Mar 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Mar 2015 |
|---|---|
| Reference | 2015-0112 |
| Deceased | Brenda Leyland |
| Coroner | Catherine Mason |
| Coroner area | Leicester (City & South) |
| Category | Product related deaths · Suicide (from 2015) |
| 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.
Aono Cory, for Leicester (City and South) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mr Norman Lamb Minister of State for Care and Support Department of Health Richmond House 79 Whitehall London SW1A 2NS CORONER lam Mrs C E Mason, Senior Coroner for Leicester (City and South Leicestershire) 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. http://www. legislation .gov.uk/ukpga/2009/25/schedule/S/paragraphi7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 07/10/2014 | commenced an investigation into the death of Brenda Kathryn Gabrielle Leyland, 63 , The investigation concluded at the end of the inquest on 20 March 2015. The conclusion of the inquest was Suicide. CIRCUMSTANCES OF THE DEATH Brenda Leyland was found deceased in a hotel room at the Marriott Hotel, Leicester on the 4th October 2014. She had recently been upset by public exposure in the media and had been researching ways to end her life. The cause of death was 1a) Asphyxia Inhalation of helium and 2) Citalopram toxicity. The deceased was able to buy helium gas freely and had bought two canisters for the purpose of committing suicide. 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) That helium gas is freely available in canisters and there appears to be no controlling measures on how many canisters can be bought by an individual. (2) The size of the helium canisters are of large volume. (3) There is no modified control valve attached to the canisters hich would restrict the volume of gas being released. ‘Town Hall Square, Leicester, LEL 9BG Tel 0116 4541030 | Fux 0116 225 2537 [6 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. | understand that a Regulation 28 letter was sent to you from the Area Coroner of Birmingham and Solihull on the 9" July 2014 regarding concerns into the death of Mr David Reginald Giles to which he received a reply from you on the 10 September 2014 referring him to another Regulation 28 letter you had received regarding the death of Matthew Satterthwaite (by the Manchester Coroner) and that the response to Mr Giles’ death was pertinent. In that letter (undated) you say that ‘officials continue to work with relevant organisations to explore other options to reduce the risk associated with helium supplied by members’ and that you could not confirm what the other options might be at that time as they were still being considered. Please now indicate to me how you have proceeded with this work with relevant organisations and whether you are now in a position to reduce the risk posed by the supply of helium. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 15 May 2015. |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons || ind Sky News | 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. ior Coroner for Leicester (City and South) Town Hall Square, Leicester, LEL 9BG Tel 0116 4541030 | Fax 0116 225 2537
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.
Agr Rt Hon Alistair Burt MP Minister of State for Community and Social Care Department of Health Richmond House 79 Whitehalf London SWIA 2NS POC3000936305 y Tel: 020 7210 4850: Catherine Mason HM Coroner for Leicester City and South Leicestershire The Town Hall, Town Hall Square Leicester LE1 9BG 2 8 MAY 2015 Neus Cocones y Thank you for your letter about the death of Brenda Leyland. I am responding as the Minister with responsibility for this area at the Department of Health. I was saddened to learn of Mrs Leyland’s death. Please pass my condolences to her family. Your report gives details of Mrs Leyland’s death and raises questions about progress in reducing the potential risk associated with helium. In particular, you noted the following:- ¢ That helium gas is freely available in canisters and there appears to be no controlling measures on how many canisters can be bought by an individual. ¢ The size of the helium canisters are of large volume. ¢ There is no modified control valve attached to the canisters which would restrict the volume of gas being released. Having reviewed the response in the case of Matthew Satterthwaite, which was sent to HM Coroner Mr Nigel Meadows, I note that the examples given showed that even small amounts of helium can be sufficient to cause death, rendering controls on availability ineffective. This has led to a number of options to address the issues you raise being considered and discarded. Work to consider the best way to respond to the increasing use of helium as a suicide method continues with our partners across government and beyond. Since helium suicide became more common, we have been working with Samaritans, the British Compressed Gases Association and leading researchers, while involving colleagues across government from the Department for Business, Industry and Skills, Public Health England and the Department for the Environment, Food and Rural Affairs. We have met the British Retail Consortium on several occasions and taken advice from the Royal College of Anaesthetists. There are however no specific outcomes to report at this time, although there is compelling evidence that reporting and portrayals of suicide in social and other media can lead to copycat behaviour, especially among young people and those already at risk. The Samaritans have produced guidelines intended to limit the further spread of both helium suicide and other novel methods. These can be found at - http://www.samaritans.org/media-centre/media-guidelines- reporting-suicide. There is a balance to be attained between ensuring that helium is available to those who wish to use it for its intended purpose of inflating balloons, while protecting those who wish to do otherwise. I am keen that we all work together to find ways to prevent any more families suffering the loss of a loved one in this way. I believe this is a priority for the Department in my policy area and will do what I can to ensure this issue is successfully resolved. Thank you for bringing this matter to our attention, I hope that you find this response helpful. Youn (atts ALISTAIR BURT
See every Prevention of Future Deaths report matching Product related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.