Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0544, written 21 Dec 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Dec 2023 |
|---|---|
| Reference | 2023-0544 |
| Deceased | Kimberley Liu |
| Coroner | Ian Potter |
| Coroner area | Inner North London |
| 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: Prevention of Future Deaths report Kimberly Anna LIU (died 7 February 2023) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Rt. Hon. Lucy Frazer KC MP Secretary of State for Digital, Culture, Media and Sport Department of Digital, Culture, Media and Sport 100 Parliament Street London SW1A 2BQ 1 CORONER I am Ian Potter, assistant coroner, for the coroner area of Inner North London. 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 17 February 2023, an investigation was commenced into the death of KIMBERLY ANNA LIU, then aged 40 years. The investigation concluded at the end of an inquest, heard by me, on 14 December 2023. The conclusion of the inquest was drug-related death, the medical cause of death being: 1a mixed drug toxicity. 4 CIRCUMSTANCES OF THE DEATH Dr Kimberly Anna Liu had become addicted to sleeping to sleeping tablets, painkilling medication, and other medications with a sedative effect in the years prior to her death. On 7 February 2023, Kimberly Liu was found unresponsive at home by her husband and an ambulance was called. Paramedics verified her death at home. Post-mortem toxicological analysis revealed numerous prescription-only medications in Dr Liu’s blood at the time of her death. Some of these medications had been prescribed by Dr Liu’s general practitioner and were at or about therapeutic levels; whereas other medications ( ), which had not been prescribed by her GP, were found at levels suggestive of excessive use. (For the avoidance of doubt and any confusion, Dr Kimberly Liu was not a medical doctor). 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: The evidence revealed that from at least 2019, Kimberly Liu had regularly accessed websites specifically aimed at selling prescription-only medications (predominantly medications with a sedative effect) that allowed repeat orders on the same day and did not require a prescription. Those websites included the following: Despite the different URLs some of the websites appear to be operated by the same company and/or individual(s), in that ordering using an identical WhatsApp number ( ) was also permitted. Correspondence from the websites, following an order being placed, included messaging that suggested that the operator(s) knew that their supply of such medication was likely to arouse regulatory suspicion. By way of example, messaging received in emails following the placing of an order, included the following: • • ‘This is to inform you that usage of the name “Sleeping Tablets” during the payment at the banks is prohibited. Kindly do not use the brand name as it can be harmful for us.’ ‘DO NOT MENTION THE PRODUCT OR WEBSITE WHEN MAKING PAYMENT.’ On one occasion in December 2021, the same website permitted identical orders of tablets within nine minutes of each other, without question or checks. Three days later a further order of was again permitted without any query. The concern here is that these websites, and potentially other similar websites, are not only operating without regulation, but that they appear to exploit already vulnerable individuals by facilitating an almost unseen feeding of dangerous medication addictions thereby placing those individuals in grave danger. Although the inquest I heard did not concern a death by suicide, the additional concern is that these websites could also be seen to equip people with the means to complete suicide. I believe that consideration ought to be given to the impact that the availability of such websites has on the population at large, together with the significantly increased risks to those who have developed an addiction to such medications or may even be contemplating acts of self-harm. I also believe that consideration ought to be given to whether and what action(s) could be taken to remove or limit access to or the availability of such websites. 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 15 February 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 and to the following Interested Person: (a) (husband of Dr Kimberly Liu). 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 Ian Potter HM Assistant Coroner, Inner North London 21 December 2023
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.
From Rt. Hon Andrew Stephenson CBE MP Minister of State for Health and Secondary Care 39 Victoria Street London SW1H 0EU 020 7210 4850 Ian Potter Assistant coroner Coroner area of Inner North London 25 March 2024 Dear Ian, Thank you for your correspondence of 21 December to the Secretary of State for Health and Social Care about the death of Dr Kimberley Anna Liu. I am replying as Minister with responsibility for medicines and medicines regulation. I am thankful for the extended time provided to the Department to provide a response following a transfer from the Department of Culture Media and Sports and the Department for Science, Innovation & Technology. Firstly, I would like to say how deeply saddened I was to read of the tragic circumstances of Mrs Liu’s death, and I offer my sincere condolences to her family and loved ones. The report raises some very important concerns around unregulated websites selling prescription only drugs, appearing to exploit already vulnerable individuals and could also be seen to equip people with the means to complete suicide. I am aware of the efforts undertaken by the Medicines and Healthcare products Regulatory Agency (MHRA) to address the illegal sale and supply of prescription medications, which is an Executive Agency of the Department. The MHRA is the UK regulator for human medicines and is responsible for enforcing the Human Medicines Regulations 2012. The MHRA has identified the illegal sale and supply of human medicines as a global challenge. This includes the sale of prescription drugs from unregulated sources. Criminal gangs, often based overseas, advertise medicines through illicit websites resembling those of legitimate pharmacies, while others exploit online marketplaces or sell social media platforms. The MHRA has a dedicated Criminal Enforcement Unit (CEU) that works with partners across government and policing to prevent and disrupt this illegal trade and to bring to justice those involved. The CEU monitors online channels for evidence of illegal activity and takes proportionate regulatory action. This includes using the full range of the Agency’s powers to investigate and prosecute offenders where necessary and appropriate. The unit also works to remove illegally trading websites and remove criminal profits from offenders. Through its #Fakemeds communications campaign the MHRA also provides quick and easy tools to help the public avoid buying illegally traded medicines when they shop online. Following our enquiries with the Department for Science, Innovation and Technology, my officials inform me that under the Online Safety Act 2023 all in-scope services such as user- to-user platforms and Search services will have new duties to prevent users being harmed by illegal content that they encounter via their services. User-to-user platforms will also need 1 to take steps to reduce risks that their services are used to perpetrate offences. These duties extend to the unlawful supply, or offer to supply, of controlled drugs. Platforms and Search services will need to take steps to prevent users encountering illegal sale of drugs content via their services. Platforms will need to remove this content when it does appear. You may wish to contact the Department for Science, Innovation and Technology for more detailed information regarding how the Online Safety Act will address illegal and harmful self-harm and suicide content. I would like to assure you that the Government remains concerned about the prevalence of suicide and self-harm content online and there are multiple actions in place to reduce and restrict access to such websites. The Department has taken a lead role in an emerging method working group, which brings together a range of government departments, public sector agencies academics and voluntary, community and social enterprise sector organisations to identify and tackle emerging methods of suicide. With respect to your concerns around websites which could be seen to equip people with the means to complete suicide. The suicide prevention strategy for England, published on 11 September 2023, identifies promoting online safety and tackling methods of suicide as priority areas for action. We have also launched a national near real time suspected suicide surveillance system in November 2023 to improve the timely reporting and action to prevent suicides. This will support the rollout of a new national alert system to notify schools, universities, and charities of emerging methods of suicide and risks. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, Rt. Hon Andrew Stephenson CBE MP Minister of State Health and Secondary Care
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