Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0170, written 3 May 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 May 2016 |
|---|---|
| Reference | 2016-0170 |
| Deceased | Darren Mindham |
| Coroner | Selena Lynch |
| Coroner area | South London |
| Category | Suicide (from 2015) |
| 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.
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: Rt Hon Jeremy Hunt, Secretary of State for Health CORONER | am Selena Lynch senior coroner for the coroner area of South London 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. http:/Awww.legislation.gov.uk/uksi/2013/1629/requlation/28/made 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. 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. 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 control 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. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 28" June 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 3" May 2016 Dia Meee SIGNED BY CORONER
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.
RG Rt Hon Alistair Burt MP Minister of State for Community and Social Care Department of Health Richmond House 79 Whitehall Senior Coroner swia INS Coroner’s Office Tel: 020 7210 4850 St Blaise Buildings, Bromley Civic Centre, Stockwell Close, 04 JUL 2016 Bromley BRI 3UH Gow Oh Cyach , Thank you for your letter of 3 May 2016, following the inquest into the death of Darren Mindham. I was sorry to hear of Mr Mindham’s death and wish to extend my condolences to his family. Your concern in this case focuses on the classification of the drug Pentobarbital, under the Misuse of Drugs Regulations 2001, and its subsequent availability and use as a means of suicide. Evidence shows that reducing access to the means of suicide can be effective in reducing the rate of suicide. You have suggested that Pentobarbital could be subject to the stricter controls applied to drugs found in Schedule 2 of the Regulations. This is not however a matter for the Department of Health. The Advisory Council on the Misuse of Drugs (ACMD) makes recommendations to government on the control of dangerous or otherwise harmful drugs, including classification and scheduling under the Misuse of Drugs Act 1971 and its regulations. ACMD is an advisory non- departmental public body, sponsored by the Home Office and is the lead organisation in this area. I would therefore advise that you re-direct your Regulation 28 letter to the following contact for a response on this matter. ACMD Secretariat c/o Home Office Advisory Council on the Misuse of Drugs Secretariat Ist floor, NE Quarter, Peel Building 2 Marsham Street London SWI1P 4DP With regard to methods of suicide, the Department of Health continually monitors trends in suicide data. Where we identify an increase in a particular method of suicide or observe a new method emerging, we will take appropriate action to reduce access to the means of suicide. One example where we have been successful is in reducing access to paracetamol as a means of suicide. Of course, other drugs are also used in suicide. We continue to have discussions with the Medicines and Healthcare Products Regulatory Agency about practical steps that could be taken in relation to medicines used in suicide. I hope that this reply is helpful and I am grateful to you for bringing the circumstances of Mr Mindham’s death to my attention. i ALISTAIR BURT
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