Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0043, written 4 Feb 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Feb 2023 |
|---|---|
| Reference | 2023-0043 |
| Deceased | Kirsty McKie |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: The Foreign Secretary
1 CORONER
I am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester
South
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 9th August 2022 I commenced an investigation into the death of Kirsty
Margaret McKie. The investigation concluded on the 24th January 2023 and the
conclusion was one of Narrative: Died from the complications of methanol
poisoning after she had unknowingly consumed methanol believing it to
be alcohol fit for human consumption. The medical cause of death was 1a)
Methanol Toxicity
4 CIRCUMSTANCES OF THE DEATH
Kirsty Margaret McKie was a UK national who lived and worked in Bali. She ran
a successful business as a talented ceramicist. On 22nd July 2022 she had
consumed what she believed to be alcohol. The following day she felt unwell.
She went to a hospital in Bali where she deteriorated and died on the 24th July
2022 despite treatment. Post-mortem examination included toxicology. It was
found that she had methanol in her system which had caused her death.
Methanol is not meant for human consumption. She had inadvertently
consumed methanol believing she had consumed alcohol. The methanol had
been sold as being alcohol fit for human consumption when it was not and
caused her death.
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.
1
The MATTERS OF CONCERN are as follows. –
The Inquest heard evidence that there is a growing problem of methanol being
passed off as alcohol for human consumption particularly in places such as Bali.
Methanol is used rather than ethanol in spirits aimed at the Western market and
sold even through apparently reputable suppliers.
The evidence before the Inquest was that :
1. Knowledge of the problem amongst the expatriate/tourist community was
very low despite the increase in the problem and the catastrophic
consequences of methanol consumption;
2. There was little publicity by the UK Government of the risk in contrast to
the approach taken by the Australian Government who had undertaken a
campaign to increase awareness to protect their citizens travelling in
areas of Asia such as Bali;
3. The UK Government publicising information about the risk of methanol
being used in local spirits, steps that could be taken by UK nationals
travelling to reduce the risk and warning signs of methanol toxicity would
help to reduce the chance of others dying in the way in which Kirsty
McKie died.
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 1st April 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 namely Miss McKie’s Father on behalf of the Family, 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
2
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
Alison Mutch OBE
HM Senior Coroner
04.02.2023
3
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.
The Rt. Hon Anne-Marie Trevelyan
MP
Minister of State (Indo-Pacific)
King Charles Street
London
SW1A 2AH
www.gov.uk/fcdo
27 March 2023
Alison Mutch
Coroner Area of Greater Manchester South
Dear Coroner,
I am writing in response to your report dated 4 February, following the inquest into the
death of Kirsty Margaret McKie on 22 July 2022 in Bali. I am replying as the Minister of
State for the Indo-Pacific. We welcome the opportunity to inform you of actions we have
taken, or propose to take, in response to your report. In doing so we again reiterate our
sincere condolences to the family and friends of Ms McKie.
In your report, you note three areas of concern. These are stated and addressed below.
The Inquest heard evidence there is a growing problem of methanol being passed off as
alcohol for human consumption particularly in places such as Bali. Methanol is used
rather than ethanol in spirits aimed at the Western market and sold even through
apparently reputable suppliers.
The evidence before the Inquest was that:
1) Knowledge of the problem amongst the expatriate/tourist community was very
low despite the increase in the problem and the catastrophic consequences of
methanol consumption’;
2) There was little publicity by the UK Government of the risk in contrast to the
approach taken by the Australian Government who had undertaken a campaign
to increase awareness to protect their citizens travelling in areas of Asia such as
Bali;
3) The UK Government publicising information about the risk of methanol being
used in local spirits, steps that could be taken by UK nationals travelling to reduce
the risk and warning signs of methanol toxicity would help reduce the change of
others dying in the way in which Kirsty McKie died.
The FCDO is aware that there is a risk of methanol poisoning in Indonesia and we have
had long-standing information in our Indonesia travel advice about the risks of methanol
poisoning. We encourage British nationals to read our travel advice and sign up for
alerts to see when the advice changes. The British Consulate in Bali has in the past
raised awareness about methanol poisoning in collaboration with Australian based
charity, Red Frogs. The Consulate prioritises its public campaigns across a range of
issues that affect British nationals visiting Bali. In light of your report, we have
considered what further actions we could take on methanol poisoning:
Travel Advice
FCDO Travel Advice aims to provide objective information and advice. Its purpose is to
help British nationals make better-informed decisions about international travel. We
keep our travel advice under regular review to ensure if reflects our current assessment
of the risks in each country and that it contains information relevant to British nationals.
FCDO Indonesia travel advice has flagged the risk of methanol poisoning for at least the
last 10 years. In July 2022, travel advice said:
“Methanol poisoning
There have been a number of deaths and cases of serious illness of locals and foreign-
ers in Indonesia caused by drinking alcoholic drinks contaminated with methanol. These
cases have occurred in bars, shops and hotels in popular tourist areas like Bali, Lombok,
the Gili Islands and Sumatra. Criminal gangs have been reported to manufacture coun-
terfeit replicas of well-known brands of alcohol containing high amounts of methanol.
Take extreme care when buying spirit-based drinks, as bottles may appear to be genu-
ine when they’re not. There have also been cases of methanol poisoning from drinking
adulterated arak/arrack, a local rice or palm liquor. If you or someone you’re travelling
with show signs of alcohol induced methanol poisoning or drink-spiking, seek immediate
medical attention.”
We have considered how we might further strengthen this language and, in consultation
with relevant UK health agencies, have updated travel advice to better illustrate the risk
of methanol poisoning in Indonesia, the likely symptoms, and actions British nationals
might take to try to avoid this happening.
We are also considering if there is a need to reflect the risks associated with methanol
poisoning in any other country travel advice to help British nationals to make better-
informed decisions when they travel. We will consider how to represent this alongside
other risks to British nationals so that we set out all relevant risks proportionally.
Awareness-raising
In response to the report, the British Consulate in Bali has reached agreement with the
local airport authorities to place an information banner (hardcopy and digital on all airport
TVs) about the risks of methanol poisoning in the international arrival area live from June
to December this year. Permission to display the banner will be reviewed annually. The
Consulate will also post the digital banner on their Facebook and Twitter pages, and will
encourage people to re-post it to reach a wider audience. Once the banner design is
ready, they will also share it with local social media groups.
We will engage our contacts in the UK Travel Industry to make them aware of the risks
of methanol poisoning and highlight our messaging in Travel Advice allowing travel firms
to bring the issue to the attention of their customers.
We will also ask our Student Brand Ambassadors, a network of young people made up
from UK universities and Further Education colleges to warn people of the dangers of
methanol poisoning, not limited to travel to Bali, and ask them to amplify our key
messaging, via social media and blogs.
More broadly, the FCDO’s established Travel Aware campaign will continue to prompt
British nationals who are planning to travel abroad to read the latest FCDO travel advice
for their destination and to sign up for e-mail alerts.
The FCDO will continue to review our consular services to improve the help we give
British nationals, including drawing on user research and all forms of feedback from
those who have used our services. We will continue to strive to do more for those who
need more help.
Yours sincerely,
The Rt. Hon. Anne-Marie Trevelyan MP
Minister of State for the Indo-Pacific
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