Linda Baranowski

Food
Standards
Agency

fer ict crea

Mr Geoffrey Sullivan
Senior Coroner,

The Old Courthouse,
St Albans Road East,
Hatfield,
Hertfordshire,

AL10 OES. 16th August 2017.
Your reference: 3756.

Dear Mr Sullivan,

Report into the death of Mrs Linda Jean Baranowski.

| am writing in response to the request made under paragraph 7, schedule 5, of the Coroners and
Justice Act 2009 and regulation 28 and 29 of the Coroners (Investigations) Regulations 2013 into the
death of Mrs Linda Jean BARANOWSKI, dated the 22"? June 2017, and the conclusion that her death
was likely caused as a result of an inflammatory response to the dietary supplements she was using
in the period leading up to her death on the 25" February 2016.

The regulation 28 request was also sent the Head of Community Safety Directorate for Hertfordshire
Trading Council.

This response outlines the specific work undertaken by the Incidents Team of the FSA in respect of
Mrs Baranowski before and after her death, but also outlines the wider remit and strategic work the
National Food Crime Unit is coordinating against unsafe and dangerous food for sale such as 2,4
Dintrophenol.

Food Standards Agency (FSA) Incidents Team response.

The FSA Incidents Team was notified on the 1* February 2016 by the Medicines and Healthcare
Products Regulatory Authority (MHRA) and Hertfordshire Trading Standards (Herts TS) that Mrs
Baranowski had been admitted to hospital. We were informed she was in a critical but stable

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National Food Crime Unit, Food Standards Agency, CRIME U NIT.
Aviation House, 125 Kingsway, London, WC2B 6NH.

condition in hospital and had been using slimming products which included TS slimming pills, White
tea, green tea, and a slimming gel. It was not known whether this list included all of the products
that Mrs Baranawski had administered. At that time the hospital was not in a position to confirm
what was causing the illness and, therefore, were not ruling out any product, but it was suggested
that the slimming gel might be the cause. [Note: FSA is responsible for food products; cosmetic
products or anything deemed to be medicinal would come under the responsibility of the MHRA]

Enquiries indicated that the products were purchased via the online selling site Ebay from a
Hertfordshire retailer who had been supplied by other UK Ebay suppliers. The Hertfordshire retailer
contacted all of her customers to instruct them to cease using the products immediately and this
was overseen by Hertfordshire Constabulary and Herts TS department. Herts TS also contacted the
Trading Standards departments where the UK suppliers were based.

On the 2nd February 2016 the FSA Incidents team conducted checks of their database for any
records relating to the products, suppliers or Food Business Operators that had been notified as
being involved in the production or supply of the TS slimming pills. This revealed that one of the
suppliers had been the subject of a previous incident due to the presence of ephedrine, which
meant the products were regarded as medicinal and would be controlled under medicines
legislation. The Medical Health Regulatory Authority (MHRA) had been informed of this latest case
so we did not refer it to them for advice as we would have done otherwise. Herts TS sought to
obtain samples of the product(s) for testing, either from the hospital or from the police (who had
been handed some product from some of the other 39 consumers who purchased the product). The
presence of the chemical 2,4 Dinitrophenol was unconfirmed and the Incidents team were content
that the local Trading Standards (and police) had acted promptly and appropriately to reduce risk to
others who had bought the package of products. This remained an apparent safety issue of
undetermined causality and we had no further information on which to act.

On the 17th March 2016, having requested an update, the Incidents Team were informed by Herts
TS that they consumer had died several weeks before and that Hertfordshire Constabulary were
investigating the circumstances around the death. Herts TS were awaiting information on the cause
of death but had analysed some of the same slimming tablets that had been supplied by the same
retailer for 2,4 Dinitrophenol (DNP), a dangerous chemical that has been used as a slimming pill but
is not intended for human ingestion. The FSA were advised that DNP had not been detected, and
are awaiting the quantitative analysis of HCA. They also had some slimming gel analysed for DNP
but this was not found to be present either. The Incidents team were informed that Herts TS had
made some follow up enquiries and taken the products off EBay but noted some were still available
elsewhere (e.g. Amazon).

On the 19th April 2016 FSA Incidents contacted Herts TS to seek an update on the cause of death
and any further information (such as results for some further tablets that were being tested) and

were informed that there was no further information available.

We have been notified by Herts TS of the following specific samples tested as part of their
investigation:

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saa National Food Crime Unit, Food Standards Agency, CRIME U NIT

Aviation House, 125 Kingsway, London, WC2B 6NH.

e = T5 Garcinia Extreme Tablets (TS sample number 01625)

¢ Green and White Tea Bags TS sample numbers 01623 & 01624 (received from Herts police,
original supplier no product left)

@ Hot Yili Balo Body Slimming Gel (TS Sample number $56098)

@ ~~ Balo Chilli gel (TS Sample number $56099)} Chilli Gel (TS sample number $560100})

The samples were all sent to the Public Analyst to test for the presence of DNP (it is a breach of
general food law to sell this for human consumption) , the ingredients and labelling for compliance
with the General Product Safety Regulations 2005, Cosmetic Product Enforcement Regulations 2013
and the Food Safety Act 1990.

Sample numbers 01623 and 01624 Green & White Teabags could not be analysed due to cross
contamination and all being mixed up in the same bag.

Sample 01625 TS Garcinia Extreme Fat Burner was compliant with regards to DNP- No DNP was
detected. No other safety issues to be investigated by Trading Standards.

Sample Number $56098 Hot Yili Balo Body Slimming Gel - It is the Public Analyst opinion it was not a
Cosmetic Product. There was no DNP detected.

Sample Number $56099 Hot Yili Balo Body Slimming Gel - It is the Public Analyst opinion it was not a
Cosmetic Product. There was no DNP detected.

Sample Number $56100 Hot Yili Balo Body Slimming Gel - it is the Public Analyst opinion it was not a
Cosmetic Product. There was no DNP detected.

NFCU Activity

The NFCU continues to take steps to tackle the marketing and sale of 2,4 dinitrophenol (DNP). Owing
to the dangers posed to the public tackling the illegal sale of DNP is one of the unit’s highest
priorities and will continue to be so. Whilst we have had some success in this area and there are
encouraging signs that this is beginning to have a deterrent effect on both suppliers and potential
users of the chemical there is still work to be done and we will continue to direct resource at this
issue.

Figures on cases of DNP toxicity in the UK are compiled by the National Poisons Information Service
{NPIS). The NPIS is the UK Department of Health approved, and Public Health England
commissioned, national service that provides expert advice on all aspects of acute and chronic
poisoning. In 2016, fourteen cases of DNP poisoning were reported, resulting in one fatality. This is
in comparison to 2015 during which there were thirty-five cases reported with six fatalities. The NPIS
data shows a steady decline in TOXBASE’ access and telephone enquiries to the NPIS since the
second quarter of 2015. The decline in reported cases and enquiries of NPIS corresponds with the
NFCU targeted operation against the sale of DNP for human consumption. The NFCU is aware of
only one UK death from DNP toxicity in 2016, and have been informed of a further death in February
2017 and inquiries continue into the circumstances of this fatality.

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The NFCU has continued to promote the #dnpkills message on social media, most recently with the
launch of pictorial e-cards warning the public of the dangers of DNP. Press releases have also been
issued along with information on the FSA website.

Much of the market for DNP is via the internet which brings its own set of challenges, especially as
most of the websites are neither hosted nor operated from within the UK. Nonetheless the NFCU is
actively seeking out opportunities to make interventions including regular monitoring of the internet
to identify those websites selling DNP.

Please do not hesitate to contact me if you require any further information.

Yours sincerely,

electronically

Head of Intelligence.

National Food Crime Unit

Food Standards Agency

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Internet: www.hertfordshire gov.uk

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Director of Community Protection & Chief Fire Officer: ertfordshire
Mr Geoffrey Sullivan Trading Standards
The Senior Coroner Postal Point MU104
The Old Court House Mundells
St Albans Road East Welwyn Garden City AL7
1F
Hatfield Email:

AL10 OES Contact:
My Ref: GP/EH
Your Ref:

Date: 16 August 2017

Dear Mr Sullivan,

Response to Regulation 28 Report to Prevent Future Deaths
Linda Jean Baranowski deceased

| refer to your report following the tragic death of Linda Baranowski.

On receipt of your report | instigated research by Hertfordshire Trading Standards Officers
to gain an initial understanding as to the availability of the products referred to in your
report, and those products of a similar nature. To this end a ‘test purchase’ was aiso
carried out in relation to one similar product, and labelling issues with this product will be
followed through with the appropriate loca] Trading Standards Service and supplier.

Our research has indicated that products of a similar kind and nature to those referred to in
you report are available and accessible to consumers nationwide particularly over the
internet, and we therefore consider that this issue requires national, rather than local
consideration and coordination.

Hertfordshire Trading Standards therefore undertakes to further liaise and work with the
lead national government agencies and regulators on the safety of food products,
supplements and topical creams in examining what further can be done to address your
concems in relation to the listed products. Hertfordshire Trading Standards pledges to
offer input into the development of a national strategy on this issue if required and which
the Food Standards Agency (being the lead national agency on food safety matters),
deems appropriate.

For your information at a national level in trading standards, there is a National Trading
Standards Board (which is funded Government through the Department for Business,
Energy and Industrial Strategy) which amongst other things helps to co-ordinate safety
issues on a national basis, and the Association of Chief Trading Standards Officers, which

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also can aid the Food Standards Agency and others in co-ordinating and delivering any
nationa! approach

| note that one of the products; the Hot Anti-Cellulite Balo slimming cream gel chill 85m! is
not a food product or supplement but a topical gel (not covered by the Food Standards
Agency), and we would welcome and encourage a coordinated approach from colleagues
at a-national level led by the Food Standards Agency following their liaison with the
Medicines and Healthcare Regulatory Agency and the Department for Business, Energy
and Industrial Strategy covering general product safety in relation to such products.
Hertfordshire Trading Standards will respond to their direction and suggestions as they
develop.

Yours sincerely

(

Deputy Director, Community Protection

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