Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0153, written 21 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 | 21 Apr 2015 |
|---|---|
| Reference | 2015-0153 |
| Deceased | Anthony Garrett |
| Coroner | Rachael Griffin |
| Coroner area | Manchester (West) |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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 (1) NOTE: This form is to be used after an inquest. | REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Home Secretary, the Rt Hon Teresa May MP 2. The Minister of State for Crime Prevention, the Rt Hon Lynne Featherstone 3. The Advisory Council on the Misuse of Drugs 7 1 | CORONER T am Rachael Clare Griffin, Assistant Coroner, for the Coroner Area of Manchester West 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 the 5" November 2014 I commenced an investigation into the death of Anthony Peter Kristian Garrett, born on the 11" July 1979. The investigation concluded at the end of the inquest on the 10" April 2015. The Medical Cause of Death was la Hypoxic-Ischaemic Encephalopathy 1b Toxicity from alcohol and synthetic cannabinoids The conclusion of the inquest was that Anthony Peter Kristian Garrett died as a consequence of a combination of alcoho! consumption and misuse of synthetic cannabinoids. 4 | CIRCUMSTANCES OF THE DEATH On the 30" October 2014 Mr Garrett, who had been drinking alcohol throughout the day, was seen to smoke from a pipe which contained a substance called Cherry Bomb, at around lunchtime that day. Cherry Bomb is a substance that is sold as herbal incense, and is commonly referred to as a legal high. As soon as Mr Garrett had smoked this substance he was seen to collapse. Although he was initially thought to be asleep, it was soon established that he was unconscious, and the North West Ambulance Service was contacted. He was transported to the Royal Bolton Hospital, Bolton, but sadly he never regained consciousness, and died the following day. _ a 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 inquest evidence was heard that: Following toxicological analysis upon Mr Garrett’s blood, which was taken Post Mortem, there was found to be the presence of a compound known as STS-135, which indicated the use of synthetic cannabinoids prior to Mr Garrett’s death. This is a compound that may be marketed as herbal incense. Cherry Bomb is a substance that is marketed as herbal incense and although it is sold with a warning that it is not for human consumption, it is a substance that is misused by people who smoke it. Cherry Bomb was the substance that Mr Garrett was seen to smoke immediately before his collapse, and so is believed to have contained the compound STS-135, the synthetic cannabinoid that was found within his post mortem blood. This use of synthetic cannabinoids, together with the consumption of alcohol led to Mr Garrett’s death, however it was felt that it was the synthetic cannabinoid which had caused the sudden collapse, as the substance is known to cause irregular heartbeats, and can therefore trigger a fatal arrhythmia. Although the death was a combination of the alcohol and synthetic cannabinoid, it was confirmed that the synthetic cannabinoid in itself is dangerous and potentially harmful and the effects of the substance are unpredictable. 2. Ihave concerns that Synthetic Cannabinoids are readily available substances in the community, which are legally and commonly sold as herbal incense. They are sold with a warning that they are not for human consumption, but are misused and consumed by people. Consequently they can be dangerous and potentially life threatening to those who use them in this way. 3. I therefore request that the above concerns are considered and a review is undertaken regarding the status and control of these dangerous substances, 6 | ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation have 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, 16" 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 T have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) Mr Garrett’s sister on behalf of his family Tam 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 | Dated 21* April 2015 Rachael C Griffin
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