Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0191, written 15 May 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 May 2015 |
|---|---|
| Reference | 2015-0191 |
| Deceased | Jacques Lakeman and Torin Lakeman |
| Coroner | Alan Walsh |
| Coroner area | Manchester (West) |
| 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 (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. Rt Hon Teresa May, Home Secretary, The Home Office, 2 Marsham Street, London, SW1P 4DF CORONER Iam Alan Peter Walsh, H M Area Coroner, for the Coroner Area of Manchester West CORONER'S LEGAL POWERS T 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 4°" December 2014 I commenced an Investigation into the deaths of Jacques Gerard Lakeman, 20 years, born on the 27" February 1994 and Torin Callan Lakeman, 19 years, born on the 30 May 1995. The Investigation concluded at the end of the Inquest on 28" April 2015. The medical cause of death in relation to both Jacques Gerard Lakeman and Torin Callan Lakeman was: 1a) Fatal MDMA toxicity. The conclusion of the Inquest in relation to both Jacques Gerard Lakeman and Torin Callan Lakeman was Misuse of Ecstasy. CIRCUMSTANCES OF THE DEATH 1. Jacques Gerard Lakeman and Torin Callan Lakeman died at [I The Grapes Public House, Stoneclough, Bolton on the 1* December 2014. 2. Jacques and Torin were brothers, who met in Manchester on the 29" November 2014 to attend a football match on the same day played between Manchester United and Hull City at Old Trafford, Manchester. The brothers were born in the Isle of Man and at the time of their deaths Jacques was working in London and Torin was a student studying at Aberystwyth University, Wales. They travelled separately to Manchester on the 29" November 2014 before going to the Grapes Public House, where they had arranged to stay overnight. 3. They attended the football match during the course of the afternoon of the 29" November 2014 before returning to the Public House at approximately 20:00 hours in the evening. 4, Both men were seen at approximately 21:15 hours on the same evening when they visited a nearby shop before returning to the Public House and they went to their room shortly after returning from the shop. 5. Jacques and Torin were not seen again after approximately 21:30 hours on the evening of the 29° November 2014 until they were found on the 1* December 2014 after concerns were raised by their family when they failed to return to their addresses in London and Aberystwyth respectively. 6. Evidence was given at the Inquest by a friend of Torin, who was a fellow student at Aberystwyth University, that Torin had obtained MDMA (Ecstasy) during the week prior to the 29" November 2014 by using the Internet. He used the Internet by a route referred to as the “Dark Internet” or the “Dark Web”, which exists as a form of a “secret” Internet behind a veil and hidden from legitimate Internet use. The website used by Torin was named as Agora and he used a method of access named as “Tor”. Evidence was also given that illicit substances, including Class A drugs and prescribed medications, could be obtained by use of the website. 7. The Ecstasy drug was obtained by Torin using the Internet and the drug was delivered to Torin’s home address in Aberystwyth by post in a padded envelope using the Postal System. It is not Known whether the drugs were supplied from an address in the United Kingdom or whether the drugs were imported from abroad. CORONER'S CONCERNS During the course of the Inquest the evidence revealed matters giving rise to concern and 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: i. Torin had received supplies of drugs, prior to November 2014, by use of the Internet using the “Dark Internet” or “Dark Web”. The Inquest heard that access to the “Dark Internet” or “Dark Web” would be difficult without having knowledge or expertise in relation to Internet access but young persons, particular intelligent University students, would find access to the websites to be relatively easy and it would not be difficult for such persons to obtain access to illicit activities, including the supply of illicit drugs. The websites are anonymous and there is no contact information with regard to the address or location of the owners of the website nor with regard to the suppliers of illicit drugs. The constituent parts of the drugs, including the strength and content of the drugs, are unknown and may contain contaminants and further illicit substances creating an additional risk. There is no regulation of the supply of drugs by use of the Internet and there is no protection in place in relation to the delivery or importation of drugs using the Internet and delivery to a United Kingdom postal address by use of the Postal System. The evidence raised concerns that future deaths will occur unless action is taken to review the above issues, particularly in view of the supply of illicit drugs, including Class A drugs, by use of the Internet. On the 30" March 2015 I reported a similar concern to you relating to the death of Jason Houghton, who died on the 30" June 2014 from the combined toxic effects of illicit drugs obtained by use of the Internet. . IT request that you consider the above concerns particularly in regard to the following:- The supply and importation of drugs, including Class A drugs, in the manner and in the form described in this report, by use of the Internet. The regulation of the Internet, which may be difficult if not impossible, in relation to the supply of drugs and delivery of drugs to addresses in the United Kingdom by use of the Postal System. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and your organisation have 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" July 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. I have sent a copy of my report to the Chief Coroner and to the following Interested Persons :- — father of Jacques Gerard Lakeman and Torin Callan Lakeman. 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. a ee a 15™ May 2015 Alan Peter Walsh
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.
Rt Hon Mike Penning MP Minister of State for Policing, Crime, Criminal Justice and Victims Home Office — cee ee www.gov.uk/home-office Alan P Walsh H.M Area Coroner — Manchester West H.M. Coroner's Court Paderborn House Howell Croft North, Bolton BL1 1QY 07 JUL 2095 Noe Men INQUEST INTO THE DEATH OF JACQUES GERARD LAKEMAN AND TORIN CALLAN LAKEMAN — REGULATION 28 REPORT Thank you for your letter of 15 May to the Home Secretary about the tragic deaths of Jacques and Torin Lakeman from the misuse of ecstasy. | am replying as the Minister for Policing, Crime, Criminal Justice and Victims with responsibility for drug policy. | note your request for action concerning: i. the supply and importation of Class A Drugs by use of the internet; and ii. the regulation of the internet, if possible, in relation to the supply of drugs and the delivery of the drugs to the UK using the postal system. This is clearly a very tragic case involving two young brothers and | am grateful to you for raising these issues with me. As | stated in my recent letter to you regarding the death of Jason Houghton, online purchasing remains a 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) and the police routinely monitor controlled drugs 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 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. In November 2014, the NCA, working with police forces across the UK, arrested six people in strikes coordinated with international partners. Those arrested included suspected administrators for the online market place Silk Road 2.0 and another online drug market place, as well as significant vendors of illegal drugs through the dark web. Simultaneously, partners from the European Cybercrime Centre, acting on intelligence developed by US counterparts, took out technical infrastructure which was key to the hosting of illegal market places on the dark web, in total over 400 hidden services taken down. The action was part of continuing operations to target the use of online market places to trade in illegal commodities such as class A drugs, firearms and false documents. In addition, as | stated in my previous letter to you, Border Force officers are on constant alert to keep controlled drugs from entering the country. The associated enforcement response includes intelligence-led examination of packages and letters sent by post to intercept the importation of controlled substances. Working together with law enforcement partners, this activity is co-ordinated by the NCA who are continuing to enhance the security of our borders and lead the fight against serious, organised and complex crime. | hope that this letter addresses your concerns. <n ents Rt Hon Mike Penning MP
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