Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0027, written 3 Feb 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Feb 2021 |
|---|---|
| Reference | 2021-0027 |
| Deceased | Daniel Mervis |
| Coroner | Professor Fiona Wilcox |
| Coroner area | London Inner (West) |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
St John’s College,
Oxford University
c/o
, Solicitor
1
CORONER
I am Professor Fiona J Wilcox, HM Senior Coroner, for the Coroner Area of Inner West
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.
3
INVESTIGATION and INQUEST
On the 16th September 2020, evidence was heard touching the death of Daniel Brian
Mervis. Mr Mervis had died as result of a mixed drug overdose on 25th October 2019
aged 23 years.
Medical Cause of Death
I (a) Mixed drug toxicity
How, when, where Mr Mervis came by his death:
Daniel had misused drugs from his teens and this progressed to addiction and IV drug
use. His addiction relapsed and remitted and required multiple rehabilitations. He also
suffered with anxiety, depression and ADHD. In 2019 he was drug free for around 8
months but relapsed again in the last 2 months of his life. This progressed and on
24/10/2019 he arrested following drug misuse. He was resuscitated but self-discharged
form hospital. Sadly, he took more illicit substances. He was found deceased in the flat
of a known drug dealer, likely to have been supplied drugs by person or persons present
at the scene. He could not be resuscitated and was recognised as life extinct at 04:02 by
the London Ambulance Service.
Conclusion of the Coroner as to the death:
Drug related misadventure.
4
Extensive evidence was taken in court. In summary, of relevance to this report:
It was clear that Daniel was using drugs whilst at St John’s College. Concerns were
, as part of submissions in relation the duty of the
raised by Daniel’s father
coroner to write a Regulation 28 report of the conflict between the College’s policy to
deal with drug misuse severely, but also at the same time to offer support to individual’s
whose lives are blighted by drug misuse. There is no suggestion that the College should
condone illegality, but since drug addiction is an illness, then support by the College may
assist students with these issues to access appropriate care, perhaps early on in their
addiction and thus help prevent future deaths.
5
Concerns of the Coroner:
1. That Oxford University has no overarching policy agreed by all colleges, and
that St John’s should encourage the University to develop the same.
2. That there is an apparent conflict between St John’s stated policy to deal
with utmost severity with those students who misuse or supply drugs, and
the apparent support those students who suffer with drug addiction are
offered. This conflict may discourage such students to seek help for their
addiction out of fear of the consequences, either legal or disciplinary. A
policy of the College which is well publicised and stresses the confidential
nature of support offered may mitigate this risk.
3. That St John’s drug misuse policies should be more widely advertised for
example at Fresher’s week.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
[AND/OR your organisation] 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. 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 and to the following Interested
Persons :
,
By email.
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
3rd February 2021
Professor Fiona J Wilcox
HM Senior Coroner Inner West London
Westminster Coroner’s Court
65, Horseferry Road
London
SW1P 2ED
Honorary Professor QMUL School of Medicine and Dentistry
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.
Date 26 March 2021 Our Reference Your Reference Please ask for Direct Dial Facsimile Email Knights | FOR THE ATTENTION OF PROFESSOR FIONA J WILCOX HM Senior Coroner, Coroners Officer Inner West London Coroner's Office 33 Tachbrook Street London SW1V 2JR BY EMAIL. Dear Madam Response of St John’s College Oxford to the Regulation 28 Report to Prevent Future Deaths issued by the Coroner on 3 February 2021 arising out of the inquest into the Death of Daniel Mervis, Ex-undergraduate. The purpose of this communication Is to provide a Formal Response to the Coroners Regulation 28 Report outlined above, In her Report, the Coroner raised the following; Concerns of the Coroner: 4. That Oxford University has no overarching policy agreed by all colleges, and that St John’s should encourage the University to develop the same. 2. That there is an apparent conflict between St John’s stated policy to deal with utmost severity with those students who misuse or supply drugs, and the apparent support those students who suffer with drug addiction are offered, This conflict may discourage such students to seek help for their addiction out of fear of the consequences, either legal or disciplinary. A policy of the College which is well publicised and stresses the confidential nature of support offered may mitigate this risk. 3. That St John's drug misuse policies should be more widely advertised for example at Freshers’ week, In Response, St John's addresses these matters as follows; Response to Concerns 1. The Conference of Colleges (a forum for the Colleges of the University of Oxford to deal with matters of shared interest and common purpose) has set up a Task and Finish group, to be led by the Master of Pembroke College. The intention is to set up a template policy that all Colleges will be able to adopt. St John’s College will be represented on the working group by the Principal Bursar and the Welfare Dean, Kalghts ple Midland House West Way Botley Oxford OX2 OPH T 01868 811700 W knightspic.com Knights ple ts the trading name of Knights Professional Service Limited which ls a timiled company registered In England and Wales, registered no. 08453376 and authorised and ragulated by the Solicitors Regulation Authorily under number 620595, Reglstered office Is The Brampton, Newcastle-under-Lyme, Staffordshire, STE OQW. VAT na, 208 8271 04 ee — Knights: 2. St John’s will adopt the template policy outlined in response one. In addition to this it will be rewriting the appropriate section of the student handbooks to make sure that there Is greater clarity about the confidential support that students are able to receive without worrying about any potential legal or disciplinary consequences. 3. St John's will make sure that this continues to be included fully in Fresher's week. In addition, we will run a Welfare week (most likely In 5" week of the first term of the academic year) where, amongst other matters, we will try and ralse a broader awareness of drugs, the consequences of addiction and drug misuse, and the support available to students both from within St John's and from external agencies. We will work with our student representatives to make sure this is as meaningful as possible. We would be grateful if you would acknowledge receipt of this communication for our records, Yours faithfully Knigquas Knights ple
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