Prevention of Future Deaths reports · 2016

Arenijus Nedzelskies

Regulation 28 report to prevent future deaths, reference 2016-0010, written 13 Jan 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report13 Jan 2016
Reference2016-0010
DeceasedArenijus Nedzelskies
CoronerARW Forrest
Coroner areaSouth Lincolnshire
CategoryAlcohol, drug and medication related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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.

AR W Forrest tum, rrcp, FrcPath
GMC Number: 1333523

Her Majesty's Senior Coroner for South Lincolnshire

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

1. The Right Honourable Mike Penning MP
Minister for Policing, Fire and Criminal Justice
Home Office
2 Marsham Street
London
SW10 4DF 4

2. Dr Wyn Parry i
DVLA Medical Branch Chief Medical Advisor

CORONER

| am ARW Forrest, Senior Coroner for the Coroner's area of South Lincolnshire.

a |

CORONER’S LEGAL POWERS

| 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 27" August 2015 | commenced an investigation into the death of Arenijus
Nedzelskis, age 48. The investigation concluded at the end of the inquest on 12"
January 2016. The conclusion of the inquest was Narrative Conclusion: Arenijus died as
a result of self suspension by the neck. Intoxication with alcohol and synthetic
cannabinoids receptor agonists impaired his ability to form an informed intention to kill

himself.

CIRCUMSTANCES OF THE DEATH

Arenijus was a lorry driver. He was in financial difficulties as a result of spending large
amount of money on ‘Legal Highs’, specifically cannabinoid receptor agonists. Following
an argument with his partner over money he was found hanging. Post Mortem toxicology
demonstrated the presence of alcohol in his blood and urine and 5F AKB-48, 5F PB-22
and their metabolites. Empty packets of 'Night Shade’ labelled as containing 5F AKB-48

and 5F PB-22, using their full IUPAC systematic names were found at his home. The
———

Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ
Tel: 01522 553374 Fax: 01522 516717
Email: HMCeroner_Southlincolnshire@lincolnshire.gov.uk

AR W Forrest um, rrcp, FRcPath
GMC Number: 1333523

Her Majesty's Senior Coroner for South Lincolnshire

presence of these two compounds was confirmed in washings from one of the

packages.

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 That neither 5F AKB-48 nor 5F PB-22 are currently controlled by regulations
made under the Misuse of Drugs Act 1971

2 That the deceased had not reported his chronic misuse of cannabinoid receptor
agonists to the DVLA Medical Branch.

ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | 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,
namely by 9 March 2016. 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.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested

Persons:

2. DC [J cast Midlands Special Operations Unit

Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ
Tel: 01522 553374 Fax: 01522 516717
Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk

AR W Forrest uum, rrcp, FrcPath
GMC Number: 1333523
Her Majesty's Senior Coroner for South Lincolnshire

| 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.

13” January 2016 We
ARW Forrest a

H M Senior Coroner for South Lincolnshire

Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ
Tel: 01522 553374 Fax: 01522 516717
Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk

Responses

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.

Response from Home Office (PDF)
Karen Bradley MP
Minister for Preventing Abuse,
RN Exploitation and Crime

2 Marsham Street,

Home Office London SW1P 4DF

www.gov.uk/home-office

Professor ARW Forrest

H.M Senior Coroner for South Lincolnshire
Unit 1, Gilbert Drive

Endeavour Park

Boston PE21 7TQ

INQUEST INTO THE DEATH OF ARENIJUS NEDZELSKIS —
REGULATION 28 REPORT

—2 MAR 2016

Thank you for your letter of 13 January to the Home Office about the tragic
death of Arenijus Nedzelskis from self suspension of the neck whilst
intoxicated from alcohol and synthetic cannabinoids. | am replying as the
Minister for Preventing Abuse, Exploitation and Crime, with responsibility for
drug policy.

| note your concerns that the Government should take action against synthetic
cannabinoids to prevent such deaths occurring in the future.

This is clearly a tragic case and | am grateful to you for raising this issue with
me.

The landmark Act to end the trade in harmful psychoactive substances and
protect young people from the dangers of these drugs achieved Royal Assent
on 28 January. The Psychoactive Substances Act 2016 will restrict the
production, supply and importation of these potentially dangerous drugs. The
new legislation will give police and other law enforcement agencies greater
powers to tackle the reckless trade in psychoactive substances, and will see
offenders face up to seven years in prison.

We cannot, and should not, tolerate the open sale on our high streets and
over the internet of these potentially harmful substances. This landmark
legislation will fundamentally change the way we tackle psychoactive
substances 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.

In addition, we have already banned more than 500 new drugs, created the
Forensic Early Warning System to identify psychoactive substances in the UK
and support law enforcement action with the latest intelligence on new
substances. We have introduced new powers under the Anti-social
Behaviour, Crime and Policing Act 2014 which have already been
successfully used by police forces and local authorities to take action against
head shops.

We are also taking forward a comprehensive action plan on psychoactive
substances 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 psychoactive substances and
published clinical guidelines to aid in the detection, assessment and
management of psychoactive substance users.

| note your concerns that Mr Nedzelskis did not inform the DVLA Medical
Branch about his chronic misuse of synthetic cannabinoids. If a driver
becomes aware of a condition that may affect safe driving they must report it
to the Driver and Vehicle Licensing Agency. A driver could be fined up to
£1,000 if they do not tell the DVLA about a condition that might affect their
ability to drive. Additionally, a driver could also be prosecuted in the event of
an accident.

| hope that this letter addresses your concerns.

(1 e—
_-

KAREN BRADLEY MP

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