Prevention of Future Deaths reports · 2018

Henry Miller

Regulation 28 report to prevent future deaths, reference 2018-0260, written 29 Aug 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report29 Aug 2018
Reference2018-0260
DeceasedHenry Miller
CoronerMaria Voisin
Coroner areaAvon
CategoryOther 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.

M. E. Voisin
Her Majesty’s Senior Coroner
Area of Avon

29th August 2018 REF: 4

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

Foreign & Commonwealth Office
Kings Charles Street

London

SW1A 2AH

CORONER

!am ME Voisin Senior Coroner for Area of Avon

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://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7

http://www. legislation.gov.uk/uksi/2013/1629/part/7/made

INVESTIGATION and INQUEST

On 28/05/2014 | commenced an investigation into the death of Henry Jack MILLER. The investigation
concluded at the end of the inquest. The conclusion of the inquest was: Accident

CIRCUMSTANCES OF THE DEATH

Henry Miller died on 23rd April 2014 at Vereda El Aguacate, Mocoa, Putumayo, Columbia. He died as a
result of intoxication after consuming a psychoactive substance during a tribal ceremony. He was
struggling to breathe after the ceremony and it was decided that he should be taken to hospital. On the
way to the hospital he was left dead by the side of the road.

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. —

Many travellers go to this area of Columbia and some will consider participating in a tribal ceremony

Telephone 01275 461920
Email AvonCoronersTeam @bristol.gov.uk Website www.avon-coroner.com
The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL

when Yage will be consumed. Many will check with the FCO about any issues or warnings about their
travel plans. | would therefore ask you to consider whether a warning or advice should be issued to such
travellers exploring this area of Columbia so that they can receive well informed guidance before
traveling and deciding whether it is safe to participate in such a ceremony.

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 26"
October 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.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following interested persons — the family
of the deceased.
| 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.

29/08/2018

Signature
M E Vatsin Senior Coroner Area of Avon

Telephone 01275 461920
Email AvonCoronersTeam @bristol.gov.uk Website www.avon-coroner.com
The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL

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 Fco (PDF)
Consular Directorate

Foreign & Foreign and Commonwealth Office
Commonwealth King Charles Sree
SW1A 2AA

Office

28 September 2018

M E Voisin

Her Majesty’s Senior Coroner, Area of Avon
The Coroner’s Court

Old Weston Road

Flax Bourton

BS48 1UL

Dear Ms Voisin

I am writing in response to your report dated 29 August 2018, following the inquest into the
death of Henry Jack Miller on 23 April 2014 in Putumayo, Colombia.

In your report, you note your concern that other British nationals could come to harm in
similar circumstances in the future and recommend that the Foreign and Commonwealth
Office (FCO) issue a warning to prospective travellers.

The safety of British nationals abroad is a paramount concern for the FCO. Through our
foreign travel advice service, which we have provided since 1990, we aim to provide
objective information and advice to help British nationals make informed decisions about
foreign travel and enjoy safe, healthy and trouble-free trips abroad. We keep our travel
advice under regular review to ensure it reflects our current assessment of risks and
includes information on issues that may affect British nationals specifically.

Colleagues at the British Embassy in Bogota have been following local developments in this
case closely and we have been in contact with Mr Miller’s family. Following receipt of your
report, our South America team finalised a review of our travel advice for Colombia and the
wider region. We concluded that it was appropriate to include information on the risks of
participating in spiritual cleansing ceremonies in our travel advice for Colombia and
Bolivia. These updates were made on 31 August 2018. The extract from our travel advice for
Colombia, found in the ‘Local laws and customs’ section, is as follows:

Ayahuasca, or yage, is a traditional plant used in ‘spiritual cleansing’ ceremonies by indigenous
communities in Colombia, primarily in Putamayo and the Amazon region. The yage ceremony
typically involves the consumption of a brew containing dimethyltryptamine (DMT), an
hallucinogenic drug. Consumption of this brew is not regulated and its interaction with existing
medical conditions is not well understood. People have suffered serious illnésses and in-some cases
death after participating in these ceremonies.

Spiritual cleansing or yage retreats are usually some distance from populated areas, making it
difficult to access medical attention for those who need it.

Our full travel advice for Colombia, including information on areas of the country where we
advise against travel, is available on the GOV. UK website:

We continue to promote our travel advice through our established social media channels
and our TravelAware prevention campaign, which is supported by a network of over 200
travel industry partners. Our travel advice for Colombia received over 280,000 unique page
views in 2017. ;

I hope that British nationals travelling to Colombia find this update to our travel advice
useful in planning for a safe and healthy trip, and that similar tragic cases can be prevented
as a result.

Head of Consular Assistance Department
Consular Directorate
Foreign & Commonwealth Office

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