Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0315, written 23 Sep 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Sep 2019 |
|---|---|
| Reference | 2019-0315 |
| Deceased | Kristiyan Danailov |
| Coroner | Richard Middleton |
| Coroner area | Dorset |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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. Department of Environment, Food and Rural Affairs (REACH) 2. Health and Safety Executive 3. Chemical Business Association, Group House, Southmere Court, Electra Way, Crewe Business Park, Crewe, Cheshire, CW1 6GU 1 | CORONER I am Richard Middleton Assistant Coroner, for the Coroner Area of Dorset 2 | CORONER'S LEGAL POWERS I 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. 3 | INVESTIGATION and INQUEST On the 3 August 2018, an investigation was commenced into the death of Kristiyan Petrov Danailov, born on the 14" September 1996. The investigation concluded at the end of the Inquest on the 17" September 2019. The Medical Cause of Death was: 1a Consistent with cyanide poisoning The conclusion of the Inquest was suicide CIRCUMSTANCES OF THE DEATH Mr Danailov was diagnosed with Asperger’s Syndrome. He lived on the top floor of his home address where he lived with his brother and parents. He chose to isolate himself and would occasionally socialise with the family. He had been seen by the Community Mental Health Team in 2016 but had chosen not to engage in seeking any further help which was offered to him. On 28/7/18 he was found by his parents in his bedroom in an unresponsive state. A tub labelled “ ELECTROBRIGHTENING SALTS” was found next to a cardboard delivery box. The tub had a warning on the label “Contains Cyanide, Causes death by swallowing or contact with acids “. There was a delivery note and a PRODUCT SAFETY DATA sheet stating “HAZARDS IDENTIFICATION- ACTIVE EFFECTS: Very harmful if swallowing”. Paramedics pronounced Mr Danailov deceased at the scene and_ hastily withdrew in order to allow the Hazardous Area Response Team to retrieve the body. Due to the circumstances it was not possible to carry out an autopsy but analysis of a swab taken disclosed the presence of cyanide. Dorset Police investigated and contacted the supplier of the product. The product had been bought on line and delivered to the home address. The product is used in the jewellery making industry to help remove stains that occur in the plating process helping to provide a brighter finish. Mr Danailov was used to ordering items through the internet. On this purchase he had not made any previous purchases from the company. In order for anyone to purchase items from the website you needed to register and confirm that you are using the item for use in your trade. You have to confirm this again each time you click to purchase. Mr Danailov inserted a fictitious jewellers business name but provided his full name and home address. 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: 1. During the inquest evidence was heard that: See above 2. Ihave concerns with regard to the following: I. There appears to be insufficient checks carried out as to the identity of the prospective customer before hazardous items are sent out in the post. What obstacles are in place to prevent vulnerable individuals purchasing such items ? II. Are members of the industry aware of the potential risks when dealing with customers over the internet. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation 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, . 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: ee 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. 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. Dated Signed 23" September 2019 Richard T Middleton
See every Prevention of Future Deaths report matching Richard Middleton, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.