Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0042, written 21 Jan 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Jan 2016 |
|---|---|
| Reference | 2016-0042 |
| Deceased | Elvis Snelson |
| Coroner | Fiona Borrill |
| Coroner area | Manchester City |
| Category | Other 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 .
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
e Rt Hon Jeremy Hunt MP, Secretary of State for Health
1 | CORONER
! am Fiona Borrill, H.M. Area Coroner for the area of Manchester City.
2 | 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.
3 | INQUEST
On 9" September 2015 | commenced an investigation into the death of
Elvis Terrence Gene Snelson, aged 29 years. The investigation
concluded at the end of the inquest on 21" January 2016.
The cause of death was found to be:
ta Acetylfentanyl toxicity
The conclusion of the inquest was drug related death.
4 | CIRCUMSTANCES OF THE DEATH
On 27" August 2015, Mr Snelson was found unconscious in Room 23 at
Le Ville Hotel in Manchester at about 11.10am by a member of hotel staff.
Paramedics attended and cardiopulmonary resuscitation was carried out.
He was taken to Manchester Royal Infirmary by ambulance, but despite
further resuscitation, death was confirmed at 12.35pm on 27" August
2015.
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:
as to the medical cause of Mr Snelson’s death. She had
provided a post mortem report and histopathology report, which
incorporated toxicology findings. The evidence | heard confirmed that
acetylfentanyl is a ‘designer drug’ and is described as a ‘legal high’. It is
an opioid analgesic and | heard evidence that it reported as being 5-15
times more potent than heroin and 80 times more potent than morphine.
| understand that it has never been licensed for medical use and has only
been sold illegally, but as a ‘legal high’.
—_ the course of the inquest, | heard evidence frorn IEE
It appears to me that although the number of fatalities arising as a result
of acetylfentanyl toxicity are low, the toxic effects of this drug being
sedation and respiratory depression will be a particular problem if the
user is unaware that they have purchased/used an opioid drug.
|
L_|
7 {| YOUR RESPONSE
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and |
believe you and your organisation have the power to take such action.
e To publicise more widely the potential toxic effects of this drug,
which can lead to fatalities
e To circulate updated information with regard to this drug within the
NHS and via the Coroners’ Society
Additionally, | would be grateful if you would inform me as to the number
of fatalities the Department of Health is aware of having occurred as a
result of acetylfentanyl toxicity from 2014 to date.
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 8" April 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 Intérested
Persons.
| 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} {NAME OF CORONER}
See every Prevention of Future Deaths report matching Fiona Borrill, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.