Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0599, written 5 Nov 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Nov 2024 |
|---|---|
| Reference | 2024-0599 |
| Deceased | James Boland |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| 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: The Home Secretary 1 CORONER I am Alison Mutch, Senior Coroner, for the coroner area of South Manchester 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 20th June 2024 I commenced an investigation into the death of James Patrick BOLAND .The investigation concluded on the 17th October 2024 and the conclusion was one of narrative: Died from the complications of pyelonephritis probably contributed to by the complications of chronic ketamine use. The medical cause of death was 1a) Sepsis 1b) Acute Pyelonephritis on a background of Chronic Ketamine use 4 CIRCUMSTANCES OF THE DEATH On 19th June 2024 James Patrick Boland known as Jamie was a chronic user of ketamine. He had developed significant urological issues as a consequence from the ketamine use. He was found unresponsive at his home address . A post mortem examination was undertaken. He was found to have a non-fatal level of ketamine in his system, but to have died from sepsis caused by acute pyelonephritis, a complication of long term use of ketamine. 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. The MATTERS OF CONCERN are as follows. – The inquest heard evidence that previously Mr Boland had used cocaine a class A drug but, had switched to ketamine a class B drug on the basis that he perceived it to be less harmful. His perception that it was less harmful was based on the fact it is designated as a class B rather than Class A drug. The evidence before the inquest was that Ketamine is a deeply harmful substance when used outside the purposes for which it is licenced for prescribing by clinicians and that users such as Mr Boland are unable to give it up despite knowing how dangerous it is to their health. Maintaining its 1 classification as a Class B drug was likely to encourage others to start to use it or continue to use it under the false impression it is “safer”. The evidence at the inquest was that Ketamine use causes huge long term life changing health problems. In Mr Boland’s case it had caused long term urological damage and liver damage. It was the damage to his urological system caused by Ketamine that led to his death. The inquest was told that there is a significant increase in the illicit use of Ketamine and that this has led to clinicians seeing a rise in potentially fatal health problems linked to its use. The extent of these risks rarely understood by users until the damage has been done to their health. 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 31st December 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 Persons namely may find it useful or of interest. on behalf of the family , who 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 Alison Mutch HM Senior Coroner 05/11/2024 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.
Minister of State for Policing, Fire and Crime Prevention 2 Marsham Street London SW1P 4DF www.gov.uk/home-office Alison Mutch Senior Coroner HM Coroner's Office Manchester South By email c/o DECS Reference: Your Reference: 23 December 2024 INQUEST INTO THE DEATH OF JAMES PATRICK BOLAND: REGULATION 28 REPORT Dear Ms Mutch, Thank you for your Regulation 28: Prevention of Future Deaths report of 5 November to the Home Secretary about the death of Mr James Patrick Boland, which was linked to chronic ketamine use. You suggest that further action should be taken to prevent future deaths from ketamine. I am replying as the Minister of State for Policing, Fire and Crime Prevention. Firstly, any death related to drugs is a tragedy, and I was very sorry to read about the circumstances of Mr Boland’s death. The inquest found that Mr Boland had switched from using cocaine, which is controlled under Class A of the Misuse of Drugs Act 1971 (“the 1971 Act”), to ketamine, a Class B under the 1971 Act, because he thought that the classification of ketamine meant that it was less harmful. You are concerned that maintaining ketamine’s classification is likely to encourage others to start or continue to use the drug, under the false impression that it is safer than drugs controlled under Class A. Ketamine is controlled as a Class B drug under the 1971 Act. The maximum penalty for supply and production is up to 14 years in prison, an unlimited fine or both. The maximum penalty for possession is up to 5 years in prison, an unlimited fine or both. These controls are intended to discourage the use of drugs and contribute, along with other measures, to restrict misuse. Ministers are subject to a statutory duty to consider advice provided by the Advisory Council on the Misuse of Drugs (ACMD), an independent scientific advisory body, before making changes to drugs legislation. Ketamine was moved from Class C to Class B under the 1971 Act in 2014, in accordance with advice provided by the ACMD. Their recommendation was based on evidence of ketamine’s potential for harm at that time. The ACMD stated that “although there is limited evidence of ketamine misuse causing social harm, evidence of physical harm (mainly chronic bladder toxicity but also an increase in acute toxicity) has increased”. This report is available at the following link: https://assets.publishing.service.gov.uk/media/5a7ce1bbed915d7c849adce3/ACMD_keta mine_report_dec13.pdf. I recognise growing concern about the harms of ketamine. I intend to commission the ACMD to conduct an updated harms assessment of ketamine as part of the forthcoming three-year work programme commission cycle. Thank you again for your letter and bringing this matter to my attention. Yours sincerely, Minister of State for Policing, Fire and Crime Prevention
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