Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0372, written 13 Oct 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Oct 2015 |
|---|---|
| Reference | 2015-0372 |
| Deceased | Catherine Findlay |
| Coroner | Simon Jones |
| 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: - The Home Secretary, the Rt Hon Teresa May MP 2. The Minister of State for Crime Prevention, the Rt Hon Lynne Featherstone . The Advisory Council on the Misuse of Drugs CORONER Tam Simon David Allen Jones Assistant Coroner, for the Coroner Area of Manchester West 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. INVESTIGATION and INQUEST On the 27" May 2015 I commenced an investigation into the death of Catherine Mary Findlay (Formerly known as Catherine Mary Roberts), born on the 13" October 1977 The investigation concluded at the end of the inquest on the 16" September 2015. The Medical Cause of Death was 1a Methoxyphenidine and Cocaine Toxicity The conclusion of the inquest was that Catherine Mary Findlay died a drug related death. CIRCUMSTANCES OF THE DEATH . On the 24" May 2015 Catherine Mary Findlay a 37 year old with a history of drug abuse was found unresponsive and not breathing at her home address at 4 Park Street, Tyldesley Manchester by her Mother. 2. Paramedics attended and pronounced life extinct. 3. Greater Manchester Police attended the premises and found there in addition to prescribed medication a quantity of white powder with the label ‘Methoxyphenidine’ (MXP) . Evidence was heard at the Inquest that MXP is not a controlled substance which is freely available over the internet where it is sold as, research chemicals, and can be found on websites listing ” legal highs”. 5. A post mortem examination carried out on Catherine Mary Findlay concluded, in the absence of any other findings that could have explained her sudden death, that she died of as a result of a combination of MXP and Cocaine Toxicity. 6. Evidence was further produced at the Inquest that Catherine Mary Findlay had a history of obtaining substances over the internet. substance under the Misuse of Drugs Act 1971 and that this is a 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. The toxicological evidence, supported by the evidence of the Consultant Pathologist who carried out the Post Mortem examination, concluded that the cause of death was a combination of cocaine (a controlled substance under the Misuse of Drugs Act) and MXP. 2. MXP is not a controlled substance but related to Ketamine (a dis- associative anaesthetic) and is thought to be a replacement for another substance — Methoxetomine — which is now a controlled substance under the Misuse of Drugs Act. 3. Ihave concerns that such substances - freely marketed as “research chemicals” are regularly available over the internet. They are sold with a warning that they are not for human consumption but are misused and consumed by people and are consequently dangerous and potentially life threatening. 4. I therefore request that the above concerns are considered and a review is undertaken regarding the status and control of MXP. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, 8th December 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. __| is "] COPIES and PUBLICATION 1 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) catherine Findtay’s Mother. 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 sara SD |__| 13" October 2015 Simon David Allen Jones |
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.
RECEIVED Rt Hon Mike Penning MP 25 NOV 2015 Minister of State for Policing, Crime, Criminal Justice and Victims SEES oo at om ae ee mo A 2 Marsham Street, Home Office Loncon SWiP ADE Simon D. A. Jones www.gov.uk/home-office H.M Assistant Coroner— Manchester West H M Coroner's Court Paderborn House Howell Croft North Bolton BL1 1QY 23 NOV 2015 No Giver INQUEST INTO THE DEATH OF CATHERINE MARY FINDLAY — REGULATION 28 REPORT Thank you for your letter of 13 October 2015 to the Home Secretary about the tragic death of Catherine Mary Findiay from the combined effects of cocaine and methoxyphenidine (MXP) toxicity. | am replying as the Minister for Policing, Crime and Criminal Justice, with responsibility for drug policy. | note your concern that MXP can be bought online and your recommendations that the Government should review its status and consider making it a controlled substance. This ts clearly a tragic case and | am grateful to you for raising this issue with me. On 28 May. we introduced the Psychoactive Substances Bill to create a blanket ban on the supply of New Psychoactive Substances (NPS). This landmark Bill will ban the sale, supply, production and distribution of psychoactive substances for human consumption, including MXP, and give police and local authorities greater powers to tackle this reckless trade. We cannet, and cheuld not, tolerate the open sais on our high streets and over the internet of these potentially harmful substances. This landmark legislation will fundamentally change the way we tackle NPS and put an end to the game of cat and mouse, in which new drugs appear on the market more quickly than we can identify and ban them. We are also taking forward a comprehensive action plan on NPS to enhance further our response to prevention, treatment and information sharing. For example, we have launched a toolkit to help local areas prevent and respond to the use of NPS and published clinical guidelines to aid in the detection, assessment and management of NPS users. 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 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 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. The Psychoactive Substances Bill once enacted will also enable law enforcement partners to also target the psychoactive substance market, clearly criminalising their supply. 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. 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. | hope that this letter addresses your concerns. Rt Hon Mike Penning MP
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