Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0033, written 28 Jan 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Jan 2019 |
|---|---|
| Reference | 2019-0033 |
| Deceased | Jack Hubbard |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Jack Alfie Charlie HUBBARD (died 26.08.18)
THIS REPORT IS BEING SENT TO:
1.
General Manager
Egg London Nightclub
200 York Way
London N7 9AX
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 11 September 2018, one of my assistant coroners, William Dolman,
commenced an investigation into the death of Jack Hubbard, aged 18
years. The investigation concluded at the end of the inquest earlier today.
I made a determination that death was drug related.
The medical cause of death was:
1a methylenedioxymethylamphetamine (MDMA) toxicity
4
CIRCUMSTANCES OF THE DEATH
Jack Hubbard ingested MDMA at Egg Nightclub in London on the
evening of 24/25 August 2018.
1
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.
I heard evidence that the protocol at Egg Nightclub for calling an
ambulance is that before this can happen:
1. the duty manager must be called; and
2. a second set of observations must be taken, regardless of the
results of the first.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that 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 29 March 2019. I, 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
I have sent a copy of my report to the following.
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
, parents of Jack Hubbard
I 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.
2
You may make representations to me, the Senior Coroner, at the time of
your response, about the release or the publication of your response by
the Chief Coroner.
9
DATE SIGNED BY SENIOR CORONER
28.01.19
3
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