Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0480, written 27 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Nov 2023 |
|---|---|
| Reference | 2023-0480 |
| Deceased | Benn Curran-Nicholls |
| Coroner | Andrew Bridgman |
| Coroner area | Manchester City |
| 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: 1. 2. respect of Matter One. , Chief Executive, UK Health Security Agency in , Chief Executive, Manchester City Council in respect of Matter Two. 1 CORONER I am Andrew Bridgman, Assistant Coroner, for the coroner area of Manchester City 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 23.09.22 an investigation was opened into the death of Benn Curran-Nicholls who died on 19.09.22, aged 14 years. The investigation concluded on 13.11.23. The medical cause of death was 1a Refractory cardiogenic shock due to taxane alkaloid poisoning following ingestion of yew tree berries and leaves. 1b 1c 2 The conclusion was Misadventure. 4 CIRCUMSTANCES OF THE DEATH Benn Curran-Nicholls moved to Didsbury, with his family ( ) from Australia in June 2022. Benn suffered severe autism with intellectual impairment, and daily walks in the local parks became a part of his daily routine. On the morning of 18.09.22 Benn and his father went for a walk in Fletcher Moss Park where, among other things, there was a yew tree that Benn liked to climb. Benn ate some yew tree berries and also some of the leaves. Benn’s father was not aware of the poisonous nature of yew tree berries/leaves, and so took no action. Interestingly neither was, in his evidence to me, Manchester City Council’s Neighbourhood Manager for Environmental Health aware that yew trees were poisonous. Later that day at about 6pm Benn suddenly collapsed. He was admitted to Royal Manchester Children's Hospital by emergency ambulance where he died in the early hours of 19 September 2022. Toxicological evidence was that yew tree poisoning in humans was rare, but that a number of cases had been reported. 5 CORONER’S CONCERNS Matter One Following Benn’s death Manchester City Council contacted the UKHSA requesting consideration of public health messaging about the incident; for the risk assessment and 1 messaging regarding yew tree berries. The UKHSA decision was conveyed to Manchester City Council by way of email dated 72.09.22. In respect to public messaging/comms the UKHSA noted a long discussion of the risk/benefit from well-intended comms. Manchester City Council were engaged in this discussion. That email setting out, among other things, “we agreed at present that there was probably a risk of doing more harm than good from any comms put out, we would be very concerned about unintended consequences from comms messages, e.g. highlighting the risk of harm which may in turn provide a source for people to self-harm as a potential route for suicide (and therefore any comms would need to be carefully considered to justify the benefit, so it certainly shouldn’t be rushed) quantifying the risk and rationalising the ned to act know would be hard to justify => we wouldn’t recommend issuing this at present on public health grounds, given the circumstances )1 case with individualised circumstances where this is not the known cause of death, and there isn’t recognised to be a heightened risk to the wider public at present) and noting the nature of the comms means that we aren’t sharing for educational/warn and inform purposes (i.e.we aren’t telling them to be alert so they don’t mistakenly consume something, in place of an edible item, we are specifically telling them not to consume something they wouldn’t usually be eating and therefore wouldn’t usually be at risk of (yew tree berries/needles/bark). We aren’t aware of yew tree poisoning being a frequent problem but if this becomes apparent, we will certainly revisit the communications”. 1. The medical cause of death is yew tree poisoning. 2. Yew tree poisoning is rare but is documented. 3. The reason for not sending out comms messages for educational/warning and informational purposes because the message is about something that a person wouldn’t usually eat is illogical. Berries and the like might be attractive to young children who would not recognise the dangers and risks, of even illness let alone death. The poisonous nature of the yew tree is not, on the evidence, well known to the public. 4. The decision appears to be focused on comms solely about the yew tree and the risks of identifying an additional means of deliberate ingestion for suicide. No consideration was given to highlighting the risks of eating wild berries and/or leaves in more general terms. In the circumstance it is my view that the decision not to put out public health messages, either specific to the yew tree or in more general terms, was not properly and fully thought through. It should be re-visited. Matter Two I was advised through the evidence of the Manchester City Council Neighbourhood Manager that Manchester City Council are in the process of carrying out a risk assessment of the yew trees in its parks, such assessment to include dangers posed by climbing etc. The outcome of such assessments was not yet known. In respect of the highly poisonous (with fatal consequences) nature of the yew tree no assessment of that specific risk is, in my view, required. There may be other trees and plants in these parks that, if any parts are eaten, risk poisoning. I heard that the assessment did not include the identification of any such trees and plants. No consideration had been given to putting up notices warning of the poisonous nature of the yew tree, and risks of eating its berries/leaves. Neither at the entrances to the parks nor at the trees themselves. Further, no consideration had been given to the posting of notices warning, in general terms rather than specifically yew trees, that, by way of example that some of the trees and plants are poisonous and may cause severe illness and perhaps death if eaten. Again, neither at the entrances and/or dotted around the parks. 2 MATTERS OF CONCERN There is a risk of a death arising in similar circumstances, and informing the public will clearly reduce the risk of those deaths. Perhaps particularly so for a child whose carer would be so informed. 6 ACTION SHOULD BE TAKEN In my opinion action, namely further consideration, 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 Monday 22nd January 2024. 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. I have sent a copy to Benn’s mother and father. 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. 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.
UK Health Security Agency North West Cheshire & Merseyside Suite 3b, Cunard Building Water Street Liverpool L3 1DS Cumbria & Lancashire Floor C, PO Box 100 County Hall Preston PR1 0LD Greater Manchester 5th Floor, 3 Piccadilly Place London Road Manchester M1 3BN 22 January 2024 Dear Mr Bridgman Re: Ref 2023-0480, Regulation 28 report to prevent future deaths Thank you for the prevention of future deaths report sent to UK Health Security Agency (UKHSA) on 27 November 2023. Firstly, I would like to offer my sincere condolences on behalf of UKHSA to the family of Benn Curran-Nicolls who tragically died following ingestion of yew tree berries. The concerns raised in the report have been considered and reflected upon by UKHSA and its response is below. UKHSA notes that two matters of concern were raised in the Regulation 28 report. This response addresses “Matter One” only, as “Matter Two” is for Manchester City Council. UKHSA provide scientific and operational leadership, working with local, national and international partners to protect the public’s health and build the nation’s health security capability. We risk assess and take public health action including identification of source of risk and mitigation to prevent onward transmission or further harm to the public for infectious diseases and environmental issues. We work closely with a wide range of local partners including local authorities to investigate, and prevent the risk. As part of this, we communicate with the public directly, or via our partner agencies, regarding threats from infectious disease and the environment, where it is proportionate to the risk to public health and where messaging has clear actions for the public. Response to Matter One (issuing communications to the public with respect to not ingesting yew tree berries, leaves or bark) Manchester City Council were contacted by Greater Manchester Police to request consideration of proportionate messaging to be disseminated to the public. Manchester City 1 Council contacted UKHSA on 26 September 2023 requesting UKHSA to consider any messaging alongside Environmental Health and Public Health Colleagues in the Council. UKHSA public health specialist and environmental public health scientists and Manchester City Council Public Health and environmental health colleagues undertook a full risk assessment on 27 September 2023, and followed up with an email on the same date summarising the agreed position. The decision not to issue public health messaging was a joint decision between UKHSA and Manchester City Council and was made following wider discussions with key specialists between the two agencies. UKHSA have reviewed the advice provided to Manchester City Council at the time. For the reasons below, UKHSA maintains that the decision not to put out public health messages in respect of ingestion of plants, or yew tree specifically was appropriate. UKHSA respectfully disagrees that the decision “was not properly and fully thought through”. The decision was proportionate based on the assessment of risk and consideration of the utility and impact of any messaging. Assessment of risk of harm Death from toxic effect of ingested plants is very rare. The most recent data available from Office of National Statistics (2016) identifies six deaths from ingestion of plants in England and Wales1. Of these deaths, 4 were suicides, one ingestion was accidental and it was unclear whether the remaining case was accidental or suicide. Yew tree poisoning (Taxus baccata intoxication) is described in medical literature as a known poison that can lead to death. One publication reports 22 documented case studies between 1960 and August 20162. Of the 22 cases, 15 were suicides and one ingestion was accidental. It was unclear whether the 6 remaining cases were accidental or suicides. As per our previous advice provided to the Council, we maintain that there is a greater risk of doing harm than good by proactively sharing messaging with the general public to not ingest plants, or specifically yew tree, as there is a risk of unintended consequences from such messages, where it highlights the risk of harm which may in turn provide a source for people to self-harm as a potential route for suicide. 1 Number of deaths from toxic effect of ingested plants, by underlying cause, England and Wales, deaths registered in 2016 - Office for National Statistics (ons.gov.uk) 2 Guido Reijnen, Corine Bethlehem, Jacquo M.B.L. van Remmen, Hans J.M. Smit, Matthijs van Luin, Udo J.L. Reijnders. Post-mortem findings in 22 fatal Taxus baccata intoxications and a possible solution to its detection, Journal of Forensic and Legal Medicine. Volume 52, 2017, Pages 56-61, ISSN 1752-928X, https://doi.org/10.1016/j.jflm.2017.08.016. 2 Given the rarity of the issue, and that it is not possible to issue messaging which has clear actions for the public, public health communication is not deemed appropriate and has the potential to lead to unintended consequences. Action taken and proposed action In addition to revisiting the advice and risk assessment referred to above, UKHSA have highlighted the risk of ingesting yew tree berries across its partner agencies as follows: - On 7 December 2023, UKHSA North West highlighted the report to prevent future deaths and associated risk to all 24 Directors of Public Health across the NW verbally and in a presentation. As a result, Directors of Public Health were asked to consider whether any additional action should be undertaken in parks and open spaces within their local authority areas, as was highlighted to Manchester City Council. In addition, some general resources were shared with Directors of Public Health that can be shared with their residents as required (https://www.rhs.org.uk/prevention- protection/potentially-harmful-garden-plants, https://hta.org.uk/potentiallyharmfulplants). - On 20 December, UKHSA North West highlighted the report to prevent future deaths and associated risk to the other eight English regions within UKHSA and with the Devolved Administrations to highlight the potential risk. Thank you for bringing this matter to my attention. Yours sincerely, Regional Deputy Director - North West UK Health Security Agency 3
See every Prevention of Future Deaths report matching Andrew Bridgman, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.