Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0222, written 30 Jun 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Jun 2023 |
|---|---|
| Reference | 2023-0222 |
| Deceased | Victoria Storey |
| Coroner | Anna Loxton |
| Coroner area | Surrey |
| Category | Alcohol, drug and medication related deaths · Hospital Death (Clinical Procedures and medical management) 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:
__________________________________________________________
The Inquest Touching the Death of Victoria STOREY
A Regulation 28 Report – Action to Prevent Future Deaths
__________________________________________________________
THIS REPORT IS BEING SENT TO:
• The Right Honourable Suella Braverman KC MP, Secretary of
State for the Home Department,
• The Right Honourable Alex Chalk KC MP, Lord Chancellor and
Secretary of State for Justice, Ministry of Justice,
1 CORONER
Ms Anna Loxton, HM Assistant Coroner for Surrey
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7(1) of Schedule 5 to The Coroners
and Justice Act 2009.
3
INVESTIGATION and INQUEST
The inquest into the death of Victoria STOREY was opened on 24th
January 2023. Evidence was heard and the inquest was concluded on 26th
June 2023.
I found the medical cause of death to be:
1a.
Toxicity
I determined that Victoria took an accidental overdose of
,
a potent synthetic opioid not licensed for medicinal use. Victoria had a
history of opioid dependency, exacerbated by historic necessary
medicinal use and to alleviate Post Traumatic Stress Disorder following a
traumatic assault aged 18. I did not find any evidence she had intended
could not be traced
to take her own life. The source of the
despite Police interrogation of her electronic devices.
I recorded a short form conclusion of Drug Related.
4 CIRCUMSTANCES OF THE DEATH
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of
Victoria was found deceased in her bedroom on the evening of 3rd September
2022. Toxicology found she had low therapeutic levels of prescribed drugs; a
higher level of Venlafaxine consistent with chronic (not acute) dosage and
in her post mortem blood; which the Toxicologist
stated “contributed more than minimally, and possibly substantially, to the
were found in
cause of Ms Storey’s death”.
Victoria’s bedroom.
The Pathologist recorded a cause of death of 1a) Mixed drug (mainly
) toxicity). Having considered the Toxicology evidence in respect
of the other drugs being at low levels, save for Venlafaxine which was stated to
be at a level consistent with chronic dosage, I amended the cause of death to 1a)
containing
Toxicity.
is not
I heard evidence from a Drug Expert with Surrey Police that
sold under that name, but is often marketed as one of the common
pharmaceutical opiates, so the danger of taking this illegal substitute would not
be known to the end user.
5 CORONER’S CONCERNS
The MATTERS OF CONCERN are:
- Victoria had a history of opioid dependency to assist with her
mental health struggles. She had previously admitted to healthcare
professionals purchasing illicit opioids from the internet and there
was evidence of this from 2019 and 2020 on her electronic devices.
illicitly traded and marketed as common
pharmaceutical opiates. It has potent analgesic effects but is not
approved for medicinal use due to the increased risk of adverse
events.
is
-
- The Home Office requested advice from the Advisory Council on
the Misuse of Drugs (ACMD) on the appropriate domestic control
, and was advised by the ACMD on 18th July 2022
of
that
(and other similar compounds) should be
placed in schedule 1 of the Misuse of Drugs Regulations 2001 and
listed as Class A drugs under the Misuse of Drugs Act 1971.
However, at present the Act and Regulations have not been
and it is unclear if and when
amended to include
this will take place.
is not therefore currently
controlled under Class A, Schedule 1, Misuse of Drugs Act 1971
despite its heroin-like effects with a high risk of fatal overdose.
- Due to the nature of the trade in potent synthetic opiates, there is
no way for the end user to know what the illicit substance
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2
contains.
Consideration should be given to whether any steps can be taken to
address the above concerns.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I
believe that the people listed in paragraph one above have the power to
take such action.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of its date; I
may extend that period on request.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for such action. Otherwise you must
explain why no action is proposed.
8 COPIES
I have sent a copy of this report to the following:
1. See names in paragraph 1 above
2.
3. The Chief Coroner
In addition to this report, I am 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 at the time of your response, about the release or
the publication of your response by the Chief Coroner.
Signed:
ANNA LOXTON
DATED this 30th day of June 2023
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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 Chris Philp MP Minister of State for Crime, Policing and Fire 2 Marsham Street London SW1P 4DF www.gov.uk/home-office Anna Loxton HM Assistant Coroner for Surrey HM Coroner’s Court Station Approach Woking Surrey GU22 7AP By email c/o INQUEST INTO THE DEATH OF VICTORIA STOREY: REGULATION 28 REPORT Dear Ms Loxton, Thank you for your report under Regulation 28 of the Coroner (Investigations) Regulation 2013, dated 30 June and addressed to the Home Secretary and the Secretary of State for Justice, about the death of Ms Victoria Storey. I am responding as the Minister of State for Crime, Policing and Fire. At present, supply psychoactive effect may be subject to a maximum sentence of seven years’ imprisonment, an unlimited fine, or both under the Act. who know, or who are reckless as to whether, it will be used for its is subject to the Psychoactive Substances Act 2016. Those who As you note in your report, following a Government commission, the Advisory Council on the Misuse of Drugs (ACMD) provided advice in July 2022 on the harms of opioids. The ACMD recommended that they are controlled under Class A of the Misuse of Drugs Act 1971 (the 1971 Act) and Schedule 1 of the Misuse of Drugs Regulations 2001. Class A drugs are considered the most harmful to individuals and society, and those placed in Schedule 1 have no known medicinal use in the UK. The Government accepted these recommendations in February, committing to control 11 synthetic opioids, including In light of ongoing drug-related deaths and non-fatal overdoses associated with synthetic opioids in the UK, we intend to bring forward this legislation by the end of the year to come into force in early 2024. This letter can be found on GOV.UK here: Government response to the ACMD’s advice on 2-benzyl benzimidazole and piperidine benzimidazolone opioids (publishing.service.gov.uk) , under the 1971 Act and associated Regulations. The presence of synthetic opioids in the UK’s illicit drug market, as well as the health harms associated with this, is a live issue within Government. The Home Office has convened a Synthetic Opioid Taskforce to review latest evidence, assess the risk of synthetic opioids to the UK, and explore options for responding should the level of risk escalate. Membership of the Taskforce includes the National Crime Agency (NCA), the National Police Chiefs’ Councils, the Department of Health and Social Care (DHSC), Border Force, the Ministry of Justice and the Joint Intelligence Organisation. The Office for Health Improvement and Disparities (OHID) has issued a National Patient Safety Alert, which provides awareness and clear instructions for staff in health settings across the country to ensure they are prepared for anyone that may present with an overdose caused by synthetic opioids. This includes ensuring the opioid overdose- reversal drug, naloxone, is more widely available. To further support incident response planning, OHID has also updated guidance for local areas on preparing for potent synthetic opioid incidents, and this is available at: Potent synthetic opioids: preparing for a future threat - GOV.UK (www.gov.uk). As you may be aware, alongside this the NCA wrote to the Chief Coroner to ask him to alert coroners of the potential presence of synthetic opioids in apparent heroin deaths. The Government’s long-term drug strategy, From Harm to Hope: A ten-year drugs plan to cut crime and save lives, sets out our ambitious plans to improve treatment and recovery systems and reduce overall drug use towards a historic 30-year low. The drug strategy is underpinned by significant new investment totalling almost £900 million over 3 years, £532 million of which was allocated to the DHSC to improve local authority drug and alcohol treatment services. This includes creating 21,000 new places for opiate and crack users, who are most at risk from the presence of synthetic opioids in the UK’s illicit drug market. More information can be found at: www.gov.uk/government/publications/from-harm-to- hope-a-10-year-drugs-plan-to-cut-crime-and-save-lives. Our aim is that through the drug strategy, we will reduce drug related deaths and create a world-class treatment and recovery system, including being better able to respond to any future threat from synthetic opioids. The Medicines & Healthcare Products Regulatory Agency (MHRA) is the UK regulator for human medicines - responsible for enforcing the Human Medicines Regulations 2012 (HMR 2012). The illegal sale and supplying of medicines online is a global problem. Buying medicines this way is potentially dangerous as they may be unsuitable for the patient, and may contain too much or too little of the stated active pharmaceutical ingredient. Medicines sold illegally online may also be entirely fake, sometimes containing harmful non-medicinal substances not present in the genuine product. The MHRA collaborates with partners to enforce the HMR 2012 by disrupting the illegal trade in medicines and preventing falsified, unlicensed and substandard medicines from reaching the public. Robust and proportionate enforcement action is taken on a case-by- case basis, including prosecution where appropriate. The MHRA discourages the public from purchasing medicinal products from unregulated sources and to report any suspicious offers, or side effects from taking such medicines, to its Yellow Card scheme - the UK system for recording adverse drug reactions. The Agency also provides regular updates to the public via its #FAKEMEDS campaign, with advice on how to avoid fake and unlicenced medicinal products, particularly when shopping online. Given we are already in the process of controlling which I have outlined above, I consider that appropriate measures to reduce the risk of deaths like this from happening are already coming into place. I hope that you agree with my assessment, and I would like to thank you for bringing this matter to my attention. , and the other measures Yours sincerely, Rt Hon Chris Philp MP Minister of State for Crime, Policing and Fire
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