Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0049, written 15 Feb 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Feb 2018 |
|---|---|
| Reference | 2018-0049 |
| Deceased | Bethany Shipsey |
| Coroner | Geraint Williams |
| Coroner area | Worcestershire |
| Category | Alcohol, drug and medication related deaths · Mental Health related deaths |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. | REGULATION 28 REPORT TO PREVENT FUTURE DEATHS ] THIS REPORT IS BEING SENT TO: 1. Secretary of State For Health 3 CORONER | am Geraint Urias Williams, Senior Coroner, for the coroner area of Worcestershire 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 16" February 2017 | commenced an investigation into the death of Bethany Victory SHIPSEY then aged 21 The investigation concluded at the end of the inquest on 14" February 2018. The conclusion of the inquest was narrative (attached), the medical cause of death being Dinitropheno! poisoning 4 | CIRCUMSTANCES OF THE DEATH j Bethany Shipsey was a young woman with significant mental health difficulties who, on 15 February 2017, died as the result of suicide having deliberately ingested a quantity of tablets containing the drug Dinitropheno! which she had purchased over the internet She did so intending to take her own life and was admitted into the Worcestershire Royal Hospital at approximately 5:30 PM on that day. The clinicians having care of her recognised the extreme toxicity of the drug, the lack of antidote, the risk of rapid deterioration and the need for close monitoring of her condition with a view to providing supportive treatment. Notwithstanding this the clinicians failed to take sufficient or adequate steps to monitor her leaving them unprepared to deal with the rapid deterioration which ensued. There were significant failings in the care given to her which amounted to a lost Opportunity to provide supportive treatment which although probably would not have Saved or prolonged her life may nevertheless have done so, : INC During the course of the inquest the evidence revealed matters Giving rise to concem, In my opinion there is @ risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to The MATTERS OF CONCERN are as follows. - (1) : The inquest heard evidence from Prof Simon Thomas, the national clinical tead for Toxbase and an acknowledged expert in dintrophenol toxicity. His unchallenged evidence was that DNP is extremely toxic, with no known antidote and that itis becoming increasingly popular with young people as a “diet pill" and is freely available via the Internet. gave evidence to the effect that this drug is likely to cause t steps are taken to make It illegal to possess, sell or further fatalities supply the drug, Given the tragic death of Ms Shipsey in the circumstances outlined above | invite the Secretary of State for Health to consider introducing legislation to | make illegal the possession and supply of DNP- (2) (3) 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. 7] YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 12" Apri! 2018 |, 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 8 COPIES and PUBLICATION | have to the Chief Coroner and to the following Interested Peroone ane, Executive Worcestershire Acute Hospitals Trust, Chief Executive Worcestershire Health and Care NHS Trust | |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. Signed a. A ; GU Williams 15th day of February 2018 H M Senior Coroner 2
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.
Ree From Steve Brine MP Parliamentary Under Secretary of State for Public Health and Primary Care Department of Health 8 ot ondon SW1H OEU 020 7210 4850 Our reference: PFD 1120118 Mr Geraint Urias Williams HM Senior Coroner Worcestershire Worcestershire Coroner Service The Civic Martins Way Stourport-on-Severn DY13 8UN 24 APR 2018 Thank you for your letter of 15 February to the Secretary of State about the death of Ms Bethany Shipsey. I am responding as Minister with responsibility for health protection and I am grateful for the additional time in which to do so. I was extremely saddened to read of the circumstances surrounding Ms Shipsey’s death. Please pass my condolences to her family and loved ones. I can only imagine how difficult a time this must be for them. I note the conclusion of your Report that Ms Shipsey died following the ingestion of 2,4 dinitropheno! (DNP) and that you wish the Department to consider introducing legislation to make illegal the possession and supply of DNP. I would like to assure you that we acknowledge this is an extremely important issue and I share your concerns at the toxicity of this substance and its availability to those who may seek to misuse it as a body building or weight loss aide. I would also like to make clear that it is illegal to sell DNP for human consumption. DNP is a chemical compound that has legitimate uses within industry (for example, as a pesticide) but is extremely toxic and is not recommended for human consumption with severe side effects including nausea, vomiting, restlessness, sweating, dizziness, headaches, rapid respiration and irregular heartbeat, possibly leading to coma and death. There is currently no regulation or licencing requirement to possess DNP, nor is there any offence of purchasing it. 1 am advised the Home Office has no plans to control the substance under the Misuse of Drugs Act 1971. As DNP has no medicinal or health benefit, if it sold for haman consumption it becomes by default a food and is dealt with as a dangerous food under the Food Safety Act 1990. The lead for DNP therefore falls to the Food Standards Agency (the FSA). While diet pills and supplements are not typically regarded to be medicines, a product which is intended to treat an adverse medical condition such as obesity is likely to fall within the definition of a medicinal product and would be a matter for the Medicines and Healthcare Products Regulatory Agency (the MHRA). Both agencies are aware of the dangers posed by this substance when used for human consumption. It might be helpful if 1 explain some of the measures taken to eliminate the misuse of DNP and ensure that information is available to both health professionals and members of the public highlighting the dangers. The FSA’s National Food Crime Unit (NFCU) has responsibility for tackling the marketing and sale of DNP in the UK and protecting the public in this area is one of the NFCU’s highest priorities and will continue to be so. The NFCU has taken a number of actions including: e Operation Broguish. Launched in April 2015 to target the illegal sale of DNP for human consumption. The NFCU established an ongoing programme of submitting ‘abuse complaints’ to domain registrars under international web usage agreements. By March 2017, 31 abuse complaints had been submitted with 21 domain names suspended as a result. The NFCU proactively engaged with Alibaba.com, which hosts multiple sellers of DNP, to highlight the presence of sellers providing DNP for human consumption — the website now regularly removes such listings; e Operation Sycamore. Work to raise awareness among local authorities and law enforcement partners, and opening channels of communication and intelligence sharing with organisations such as UK Anti-Doping, Post Office Investigations and Royal Mail Investigations which will enhance the UK’s response to any future DNP issues. Closer working with the Border Force and police on importations of DNP that could lead to misuse; and e Working with enforcement agencies to bring to justice sellers of DNP for human consumption. Department of Health I hope you will be encouraged by the actions of the NFCU. I am assured that the NFCU recognises there is more to do and resources continue to be directed at this issue. More widely, to raise awareness among the public and potential users of this substance, the FSA has run a communications campaign ‘#dnpkills’ since 2015 which has attracted support from a Radio 1 DJ and band Primal Scream, as well as an eating disorder charity (B-Eat). You will be further interested to know that the National Poisons Information Service (NPIS), commissioned by Public Health England (PHE), monitors the enquiries received through TOXBASE (the database by which health practitioners find information on toxins) and by telephone on DNP poisonings. Where there has been a notable increase in the number of cases through this data, the FSA and PHE have taken action. For example, in 2013the FSA issued warnings about DNP and PHE put out a news story supporting the FSA warnings. In addition, educational work was carried out targeting places where DNP might be sold, or promoted, such as gyms. Also in 2013, the chief medical officers wrote to GPs and emergency departments to raise awareness of DNP and its hazards. Following a further increase in cases in 2015, again warnings were issued and measures taken to increase awareness, and I am advised an associated fall in calls and access to TOXBASE was seen. I believe that together these actions have, and will continue to have, an impact on the inappropriate use of this substance. I am assured that the NPIS will continue to actively monitor enquiries relating to DNP and that the FSA, NFCU and PHE will continue to consider what further actions could be taken to tackle this issue. Thank you for bringing the circumstances of Ms Bethany Shipsey’s death to my attention. I hope that you find this information helpful. As agreed, I am copying this response to Robin Walker MP, who has made representations on this matter to the Department of Health and Social Care.
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