Prevention of Future Deaths reports
Regulation 28 report to prevent future deaths, reference 2016 – 0295, written 15 August2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 August2016 |
|---|---|
| Reference | 2016 – 0295 |
| Deceased | Darren Mindham |
| Coroner | Selena Lynch |
| Coroner area | South London |
| Category | Alcohol, drug and medication related deaths · Suicide (from 2015) |
| 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.
In the South London Coroner’s Court Inquest touching the death of Darren Mindham Report to Prevent Future Deaths (Coroners (Investigations) Regulation 28) THIS REPORT IS BEING SENT TO: Advisory Council on the Misuse of Drugs 1 | CORONER | am Selena Lynch senior coroner for the coroner area of South London 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. http:/Awww.legislation.gov.uk/uksi/2013/1629/requlation/28/made 3 | INVESTIGATION and INQUEST On 2™ September 2015 | commenced an investigation into the death of Darren Mindham. The investigation concluded at the end of the inquest on 14” April 2016. The conclusion of the inquest was that he died from acute pentobarbital intoxication having self-administered pentobarbital at home some time on 28" August 2015 while suffering from depression. The conclusion as to the death was one of suicide. 4 | CIRCUMSTANCES OF THE DEATH Mr Mindham worked as an assistant in a veterinary practice. The evidence suggested that he removed a bottle of pentobarbital from the drugs cupboard at a former employer and kept it at home before using it to take his life some months later. 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. — Pentobarbital is a drug that is found in Schedule 3 of the Misuse of Drugs Regulations 200), and is therefore not subject to the strict contro! found in Schedule 2. Whilst there may be practical difficulties in complying with stricter control, the use of pentobarbital in suicide has become commonplace. It has been shown that reducing access to the means of suicide can be effective in reducing the rate of suicide. 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. | previously sent a report to the Secretary of State for Health, and enclose a copy of his response. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 11" October 2016 |, 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: The family of Darren Mindham Albavet Limited Vets4Pets Blackheath | have also sent it to the Veterinary Medicines Directorate, and the Royal College of Veterinary Surgeons who may find it useful or of interest. | 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. DATE 15" August 2016 focaa ke VECSIGNED BY CORONER
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