Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0405, written 16 Dec 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Dec 2022 |
|---|---|
| Reference | 2022-0405 |
| Deceased | Jack Knapman |
| Coroner | Philip Barlow |
| Coroner area | Northamptonshire |
| 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: 1. The Home Secretary 1 CORONER I am Philip Barlow, assistant coroner, for the coroner area of Northamptonshire 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 29 March 2018 I commenced an investigation into the death of Jack Knapman, age 21. The investigation concluded at the end of the inquest on 13 December 2022. The conclusion of the inquest was a narrative conclusion that Jack died as an unintended consequence of taking dinitrophenol (DNP) for weight loss and body-building. 4 CIRCUMSTANCES OF THE DEATH 1. On 21 and 22 March 2018 Jack took a substantial quantity of Dinitrophenol (DNP) for the purpose of losing weight and body- building. He developed severe toxicity and was admitted to Northampton General Hospital. Despite treatment he suffered a cardiac arrest from which he could not be resuscitated and he died shortly after 1am on 23 March 2018. 2. The inquest received evidence from the National Food Crime Unit (NFCU) and from an expert in DNP poisoning. Most of the sale of DNP is on-line. The Food Standards Agency had become aware of Jack's purchase of DNP and there was an admitted delay in sending him a letter warning of the risk, although it was not possible to conclude that this made a material difference to the outcome. 3. The evidence was that, at the time of Jack’s death, there were delays in identifying sites selling DNP, getting them taken down, obtaining lists of customers, and sending warning letters to those customers. It is important to recognise that new policies are now in place at the NFCU which provide for more effective action and timescales. 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. – DNP is a highly toxic substance. It should never be used for human consumption. Nevertheless some people do use it to assist with weight loss and body-building. There have been many deaths associated with the use of DNP and it has been the subject of previous Prevention of Future Death Reports from coroners. The inquest heard that the number of deaths associated with the use of DNP has fallen but that the risk of further deaths remains for as long as it continues to be available and used for human consumption. 1 The inquest was told that, following recent consultation, the Home Office intends to add DNP to the list of regulated poisons as an amendment to the Poisons Act 1972. The evidence at the inquest was that this would be a welcome action to help reduce its availability. However, after DNP is categorised as a poison it seems that it is not clear which organisation or Department of Government should have responsibility for monitoring and preventing its sale for human consumption. This would include identification of sites offering it for sale, investigation and enforcement. My concern is that a lack of clarity on this issue might delay an effective response to any site advertising DNP. This would clearly put lives at risk. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and 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, namely by 7 February 2023. 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: 1. Mr and Mrs Knapman 2. Food Standards Agency 3. Health Security Agency 4. Northampton General Hospital 5. Northamptonshire Police I have also sent it to interest. who gave evidence and may find it useful or of I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9 16 December 2022 Philip Barlow 2
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.
Rt Hon Tom Tugendhat MBE VR MP
Security Minister
2 Marsham Street
London SW1P 4DF
www.gov.uk/home-office
17 February 2023
Philip Barlow,
Dear Mr Barlow,
Thank you for your letter of 20 December 2022 in relation to the prevention for future
deaths report following the inquest of Jack Knapman.
I am very concerned about the tragic deaths being caused by the consumption of DNP as
a dieting aid. To this end, I have recently met with two bereaved families whose children
tragically died from the consumption of DNP and have listened closely to their testimony. I
have carefully noted the contents of your prevention of future deaths report and agree that
we must do as much as possible to safeguard those who may be vulnerable to harmful
sales of DNP.
As you note in your report, the Home Office has now laid legislation to regulate DNP as a
poison under the Poisons Act 1972. This will mean that, from 1st October 2023, DNP can
only legally be sold to a member of the public by a registered pharmacist, and then only to
a member of the public with a valid explosives precursors and poisons (EPP) licence
issued by the Home Office. We are not aware of any legitimate uses of DNP by the
general public, and therefore this would act as an effective ban on sales to that group.
The police are responsible for enforcing the Poisons Act 1972, and therefore will be
responsible for investigating unlawful sales of DNP from 1st October 2023. However, we
recognise that some sellers, including those overseas, will do everything they can to flout
regulations. To this end, work will remain ongoing in the Home Office and across
Government to do everything we can to crack down on the unlawful sale and use of DNP
by working holistically to consider all aspects of the problem.
Yours sincerely
Rt Hon Tom Tugendhat MBE VR MP
Security Minister
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