Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2022-0073, written 29 Nov 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Nov 2021 |
|---|---|
| Reference | 2022-0073 |
| Deceased | James Lacey |
| Coroner | James Adeley |
| Coroner area | Lancashire & Blackburn with Darwen |
| Category | Suicide (from 2015) · Product related deaths · 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.
Senior Coroner for Lancashire & Blackburn with Darwen
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Secretary of State for the Home Department and
copied to the Family, the Senior Coroner for East London and Lancashire Constabulary
1
CORONER
I am Dr James Adeley, Senior Coroner for Lancashire & Blackburn with Darwen
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 16 June 2020 I commenced an investigation into the death of James Michael Lacey,
otherwise known and living as Victoria Lacey aged 21 years of age. The investigation concluded
at the end of the inquest on 24 November 2021. The conclusion of the inquest was suicide.
4
CIRCUMSTANCES OF THE DEATH
James/Victoria Lacey who was living both the male and female existence, purchased
on 19 May 2020 from
may be also used for suicide as it prevents oxygenation of the blood.
in much lower concentrations or purity. The evidence of Dr
that this was a rapidly increasing method of suicide as the compound was readily available, it
was quick and easy to administer, is effective and painless and from other evidence once
administered, very difficult to reverse. On 13 June 2020 Victoria Lacey took
may be sold
, forensic toxicologist, was
.
of
is a meat preservative but
, a dose more than sufficient to cause fatality, together with other preparations advised by
certain sites on the Internet and ended her life. A detective inspector from Lancashire
Constabulary confirmed that there were no suspicious circumstances.
CORONER’S CONCERNS
5
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.
is currently a “reportable substance” or “reportable poison” under
can easily be purchased
The MATTERS OF CONCERN are as follows. –
(1) relatively small quantities of
(2) a.
Part 4 of Schedule 1 to the Poisons Act 1972. As a result, under certain
circumstances, sellers are under an obligation to report suspicious transactions,
disappearances, and thefts of the substance, in a manner prescribed by the
Secretary of State (s.3C Poisons Act 1972).
b. However, this is a much less rigorous degree of control than is exercised over
“regulated poisons” under the terms of the legislation. Those substances, which
are listed in Part 2 of Schedule 1 of the Act, are subject to requirements including
licensing, record-keeping of sales, and other restrictions in relation to the general
public.
Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB
| Fax 01772 530752
c. Both the regulated poisons and reportable poison lists can specify “concentration
limits” which restrict the obligations imposed by the legislation to chemicals in
concentrations at or above that limit. For example, ammonia is “reportable” in
concentrations at or above 10% weight in weight (w/w) and phenols are
“regulated” at or above 60% w/w. The power to specify a concentration can ensure
that low concentrations of substances are not subject to the regime but higher (and
theref ore more dangerous levels) are subject to scrutiny.
Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB
| Fax 01772 530752
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
Friday, 11 February 2022 (additional days have been added due to the Christmas and New
Year period). 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
f amily. I have also sent it to the Senior Coroner for East London and Lancashire Constabulary
who may f ind 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
Dated 29 November 2021
Signature
Senior Coroner for Lancashire & Blackburn with Darwen
Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB
| Fax 01772 530752
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