Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0184, written 25 Sep 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Sep 2020 |
|---|---|
| Reference | 2020-0184 |
| Deceased | Valdotas Gerbutavicius |
| Coroner | Nadia Persaud |
| Coroner area | East London |
| Category | Other 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.
East London Coroners MISS N PERSAUD SENIOR CORONER Walthamstow Coroner's Court, Queens Road Walthamstow, E17 SQP Telephone 020 8496 5000 Email coroners@walthamforest.gov.uk 25th September 2020 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: REF: 108334 Rt Hon ~ SW1P4Dt- 1 CORONER P, Minister of State for Security, Home Office, 2 Marsham Street, London I am Ms Nadia Persaud, Senior Coroner for East London 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. htt12 :LLwww.legislation.gov.ukLukQgaL2009L25Lschedu1eL5LQaragra 12hL7 httQ :LLwww.legislation.gov. u kL u ksiL2013L1629 LQartL7 Lmade 3 INVESTIGATION and INQUEST On the 31st January 2019 I commenced an investigation into the death of Vaidotas Gerbutavicius. The investigation concluded at the end of the Inquest on the 22nd September 2020. The conclusion of the Inquest was a narrative conclusion: From 2016 to 2018 Vaidotas Gerbutavicius purchased slimming pills containing 2,4 dinitrophenol. It is unlawful to sell 2,4 dinitrophenol for human consumption, as it is an extremely harmful substance, but Vaidotas was able to purchase these pills over the internet. On the 10 March 2018, Vaidotas ingested a large amount ofpills containing 2,4 dinitrophenol. He ingested these whilst under the influence of alcohol. His actions appear to be impulsive and he had the lethal compound immediately available to him. He was taken to hospital where supportive measures were taken. There is no antidote available. Sadly, he could not be saved and he passed away from 2,4 dinitrophenol consumption. 4 CIRCUMSTANCES OF THE DEATH Vaidotas Gerbutavicius was 21 years old when he passed away on the 10 March 2018. Vaidotas had never taken any action to deliberately harm himself prior to the 10 March 2018. From the age of 18, he was able to access slimming pills on the internet containing the lethal compound 2, 4 - dinitrophenol. He obtained these pills from a variety of internet suppliers. On the 10th March 2018, following a row with his girlfriend and having drunk half a bottle of vodka and half a bottle of rum, Vaidotas ingested a number of pills containing 2, 4 - dinitrophenol. He called his father and his girlfriend promptly after this ingestion. Emergency medical assistance was then sought. Paramedics attended and took Vaidotas to Whipps Cross Hospital. Supportive measures were put in place, in accordance with the Toxbase Guidelines. There is no antidote to DNP poisoning. Sadly, Vaidotas suffered an asystolic cardiac arrest and passed away in Whipps Cross Hospital at 13:32 hours on the 10th March 2018. 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. - 2. 1. Evidence was heard during the course of the Inquest that from 2007, to date, there have been at least 32 deaths from DNP toxicity. Many of those affected are young and vulnerable individuals. In the UK, the lead organisation tasked with the disruption of the supply of 2, 4- dinitrophenol, for human consumption is the Food Standards Agency. The Inquest received information from the Deputy Head of the National Food Crime Unit (part of the Food Standards Agency). He confirmed that "the views of the FSA Chief Executive and FSA Chair individually, is the current legislation is wholly inadequate and in no way an appropriate means by which to deal with offences that can result in the deaths of those who consume it (DNP) and these individuals are often young and vulnerable people". 3. Evidence was given at the Inquest that DNP is still readily available over the internet, as diet pills. 4. Prohibitions are in place on search engine algorithms used to prevent delivery of search results for TNT. 2, 4 - dinitrophenol is also used as an explosive, but there are no such internet protections in place to prohibit its sale. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I 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 20th November 2020. 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 Chief Coroner, to the family of the deceased and to the other Interested Persons involved in the Inquest. I will also provide a copy of this report to the local Director of Public Health who may find it useful or of interest. 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. 9 25/09/2020 Signature _ _ _ _ Ms Nadia Persaud Senior Coroner East London ----\-µt.-'--==--
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