Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0150, written 15 Apr 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Apr 2015 |
|---|---|
| Reference | 2015-0150 |
| Deceased | Stephen Myers |
| Coroner | J Hamilton |
| Coroner area | County Durham & Darlington |
| Category | Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. 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: Product Safety Department, 1 Victoria Street, London, SW1H 0ET , Department of Business, Innovations and Skills, General 1 CORONER I am Dr J R L Hamilton, Assistant Coroner, for the Coroner area of County Durham and Darlington 2 CORONER’S LEGAL POWERS I 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 2 January 2015 I commenced an investigation into the death of Stephen Paul Myers, age 49. The investigation concluded at the end of the inquest on 13 April 2015. The conclusion of the inquest was Misadventure. The medical cause of death was: 1a) Likely Isopropyl Nitrite toxicity 2) Left Ventricular Hypertrophy and Fatty Liver. 4 CIRCUMSTANCES OF THE DEATH A 49 year old man (with a background of heart disease: Left Ventricular Hypertrophy, Coronary and Valvular) was drinking in the pub on Christmas Eve (24.12.14) with friends when he drank a bottler of “Poppers” (isopropyl nitrite) which he had purchased in a local shop. He collapsed and Paramedics attempted resuscitation at the scene. He was taken to Darlington Memorial Hospital where he was pronounced dead. He had previously ingested “Poppers” without ill effects. 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) Isopropyl nitrite is sold as a liquid in a small (25ml) bottle as “English Room Odoriser”. It is known that some inhale the vapour which is thought to cause a short- lived “rush” / euphoria. The label on the bottle says” do not inhale”. It is classified in accordance with 67/548/EEC: R 23: toxic by inhalation R28: very toxic if swallowed. (2) I have received a report from West Yorkshire Analytical Services which states “ The labelling was examined with respect to the Chemicals (Hazard Information and Packaging for Supply) Regulations 2009 (CHIP) and the Regulation Classification, Labelling and Packaging of Substances and Mixtures 2008 (CLP) with the following observations:- Need upgrading for CLP to include the signal word “danger”. Pictograms need updating to CLP standard. Need to include the hazard statements suggested H225 Highly Flammable Liquid and Vapour, H301 Toxic if Swallowed, H331 Toxic if Inhaled. Precautionary statements suggested P210 Keep Away From Heat/Sparks/Open Flames/ Hot Surfaces – No Smoking, P261 Avoid Breathing Vapours, P301 and P310 IF SWALLOWED : Immediately call a POISON CENTRE or Doctor/Physician. The container requires a tactile warning. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by10 June 2015. I, 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: I 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. 9 15 April 2015 Signed: Assistant Coroner, County Durham and Darlington
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.
1 pea or Business Innovation & Skills Dr JRL Hamilton HM Assistant Coroner, County Durham & Darlington PO Box 282 Bishop Auckland Co Durham DL14 4FY European Reform Directorate, Spur 1, Fourth Floor, 1 Victoria Street, London, SW1H OET htto:/iwww.bis.gov.uk Direct Lint BIS Ref: REG28/S_P_Myers. Your Ref: JRLH.LB.2382/14 11 May 2015 Dear Dr Hamilton, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Re: Stephen Paul Myers, deceased I have received your Regulation 28 Report to Prevent Future Deaths dated 21 April 2015 following your investigation and inquest into the death of Stephen Paul Myers, aged 49 years having drunk a bottle of poppers “isopropyl nitrite”. May I first say how sorry I was to hear of this tragic incident, and if you have the opportunity would you please convey my deepest sympathies to his family. You have suggested that action could be taken by this Department in order to ensure clear labelling of products like poppers in an attempt to avoid repetitions of this tragic accident. I should clarify that BIS is not responsible for the CHIP/CLP legislation regarding the labelling of bottles of Poppers (isopropyl nitrite). This is the policy of the Health and Safety Executive. The CLP labelling on this product would depend on the concentration of isopropyl nitrite and the nature and concentration of other ingredients, and follows prescribed ‘rules’ set under EU single market legislation. Whether or not certain label statements such as ‘If swallowed: Immediately call a Poison Centre or doctor/physician’ are used depends on the classification of the product, which is based on scientific data. CLP prescribes hazard classification, labelling and packaging, and there | are no provisions in CLP that restrict supply to the public. a | Ht Department for Business, Innovation & Skills The appropriate body with the power to enforce the requirements of CHIP/CLP in the case of the labelling and other requirements of these products is the local Trading Standards Authority, in this case, Darlington. The local authority Trading Standards Service will investigate whether the product was mis-labelled in accordance with CHIP/CLP legislation and decide on an appropriate course of action. We are sending them a copy of your report and recommendations. All products intended for use by consumers are regulated under the General Product Safety Regulations (GPSR) 2005 which implements the EU’s General Product Safety Directive (GPSD). This Department has responsibility for this legislation. A producer must not supply a consumer product unless it satisfies the requirement that the product is safe (regulation 5 of the General Product Safety Regulations 2005). However it appears that the instructions for use were not followed in this case. The requirement that it should be safe for its intended use would not have been breached in this case. The Home Office has responsibility for implementing the cross-Government Drug Strategy which includes tackling new psychoactive substances (NPS), or so called “legal highs”. The Home Office continues to take action to clamp down on the trade in NPS which has claimed the lives of too many young people. To protect the public from harm, they have controlled more than 500 of these substances in the past five years, created the Forensic Early Warning System to identify NPS in the UK and supported law enforcement action with the latest intelligence on new substances. The Home Office has also published guidance which encourages local authorities and police forces to consider all available avenues to address supply in our communities. This includes using provisions in the Intoxicating Substances Supply Act 1985 which makes it an offence to supply a minor with a substance that may be inhaled (includes smoking) for the purpose of intoxication. These, and other powers, have enabled local authorities to take legal action against head shops, seize stocks and stop the consumption of these dangerous substances. The guidance for local authorities can be found at https://www.gov.uk/government/publications/action-against-head- shops. Y. Page 2/2
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