Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0103, written 13 Apr 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Apr 2021 |
|---|---|
| Reference | 2021-0103 |
| Deceased | Natasha Crabb |
| Coroner | Caroline Topping |
| Coroner area | County of Surrey |
| Category | Other 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.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: NATASHA JENNIFER IRENE CRABB __________________________________________________________ The Inquest Touching the Death of NATASHA JENNIFER IRENE CRABB A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ THIS REPORT IS BEING SENT TO: • The Right Honourable Matt Hancock MP, Secretary of State for Health and Social Care • The Right Honourable Priti Patel MP, Home Secretary 1 CORONER Caroline Topping HM Assistant Coroner, for the County of Surrey 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 An investigation into the death of Natasha Jennifer Irene Crabb was opened on the 6th July 2018. The inquest was opened on the 3rd October 2018, resumed with a jury on the 22nd February 2021 and concluded on the 11th March 2021. The jury concluded that Natasha died on the 29th June 2018 at Princess Gardens, Woking, Surrey and that the medical cause of her death was; 1a Fatal Heart Arrhythmia 1b Hydrocarbon Gas Inhalation II Myocardial Fibrosis The jury concluded that she died of an accident. 4 CIRCUMSTANCES OF THE DEATH The jury found that Natasha Jennifer Irene Crabb had a history of substance abuse and a diagnosis of Emotionally Unstable Personality Disorder. She was released from prison into an agreed address and a plan was made for her to be in contact with agencies to manage her dependencies. Natasha began abusing butane very quickly after her release from prison. From 26th to 29th June 2018, Natasha came into contact with the Police, Ambulance and Hospital services. On 29th June 218 Natasha was taken to St. Peters Hospital, was found to have capacity, and was informed that inhaling butane was harmful and could be fatal. Natasha self-discharged from St. Peters Hospital without accepting treatment on the afternoon of 29th June 2018. Inhaling butane is lawful and there are no legal powers to prevent a person with capacity inhaling butane nor to remove butane from them. Natasha continued to inhale butane gas after leaving hospital and collapsed and died at Princess Gardens, Woking that evening. 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – The evidence showed that: 1. Inhaling butane is lawful and there are no legal powers to prevent a person with capacity inhaling butane nor to remove butane from them. The effects of inhalation can be fatal. 2. There is no restriction on the amount of butane gas that can be purchased making it easy for a person addicted to inhaling butane gas to obtain large amounts of the gas at one time. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 8th June 2021. 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; the Chief Constable for Surrey, South East Coast Ambulance Service, St Peter’s Hospital, Surrey and Borders Partnership NHS Foundation Trust and Kent Sussex and Surrey Community Rehabilitation Company. 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 Signed: Caroline Topping Dated this 13th April 2021.
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.
From Nadine Dorries MP Minister of State for Patient Safety, Suicide Prevention and Mental Health 39 Victoria Street London SW1H 0EU Ms Caroline Topping HM Assistant Coroner, County of Surrey HM Coroner’s Court Station Approach Woking GU22 7AP 27 May 2021 Dear Ms Topping Thank you for your letter of 13 April 2021 about the death of Natasha Crabb. I am replying as Minister with responsibility for mental health services. Firstly, I would like to say how deeply saddened I was to read of the troubling circumstances surrounding Ms Crabb’s death and I offer my deepest condolences to her family and loved ones. Butane is a highly flammable, colourless, odourless gas. It is a hydrocarbon, found in household and industrial products and is potentially intoxicating if deliberately inhaled. Butane is commonly misused by being inhaled directly through the mouth either from cigarette lighter refills, canisters or aerosol sprays. Butane is a depressant which means it slows down brain and body responses and produces a similar effect to alcohol intoxification. The effect is short-lived, so chronic users will continue inhaling to prolong the effect. Information about the dangers of inhaling butane is available on the Government’s drug information and advice website, Talk to FRANK, available at talktofrank.com. The website includes a confidential helpline which can offer support for those using glues, gases and aerosols and give details of specialist organisations that can help. Local drug services are also be able to direct people to sources of support. Departmental officials have made contact with the Home Office, which will be providing a response to you in relation to the powers applicable under the Psychoactive Substances Act 2016. I am advised that it is an offence under the Psychoactive Substances Act 2016 to supply, possess with intent to supply, and offer to supply, a psychoactive substance, such as butane, to a person for its psychoactive effect where a person knows or is reckless as to whether it will be used for its psychoactive effect. The 2016 Act also makes it an offence to produce, import or export a psychoactive substance, for its psychoactive effect. In all these cases, there is a maximum sentence of seven years’ imprisonment. In relation to the wider context of your report, you may be interested to note that NHS England and NHS Improvement have developed their care after custody service, RECONNECT1, to engage and support more people after their release from custody. RECONNECT will work pre and post release to reconnect patients to community- based health services to ensure they maintain and continue to improve their health. It will give support at a period of transition and change. The NHS Long Term Plan made a commitment to funding the RECONNECT service2. The funding has been agreed at £20million annually by year five (2023/24) of the roll out of the service. On 20 January 2021, the Government announced a new investment of £148million to cut crime and protect people from the scourge of illegal drugs. As part of this package, £2.5million will be invested in piloting an enhanced RECONNECT service in several areas of the country. This will support offenders with the most complex needs to engage with and get the right treatment from mental health, substance misuse and other services, for up to a year after release. Offenders will be supported by expert care navigators working with health and probation services. The enhanced service will target 18 to 24-year-olds. I would also like to take this opportunity to explain the work underway to improve mental health support for people with severe mental illness. This Government is committed to expanding and transforming mental health services and we recognise that providing the right interventions at the right time is vital to improving outcomes for people with mental health issues. Under the NHS Long Term Plan, we remain committed to investing at least £2.3billion of extra funding a year in mental health services by 2023/24. New and integrated models of primary and community mental health care, backed by almost £1billion extra by 2023/24, will give 370,000 adults with severe mental illnesses, including adults with a personality disorder, greater choice and control over their care and support them to live well in their communities. In addition, the NHS has committed to ensure that 60 per cent of people with severe mental illness receive a comprehensive physical health-check and follow up, as part of the NHS Long Term Plan. 1 NHS England » RECONNECT – Care After Custody 2 NHS Long Term Plan » Health and the justice system For those with severe needs or in crisis, all NHS mental health providers have established 24/7 mental health crisis lines. I hope this response is helpful. Thank you for bringing these concerns to my attention. NADINE DORRIES MINISTER OF STATE FOR PATIENT SAFETY, SUICIDE PREVENTION AND MENTAL HEALTH
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