Edward Barnard

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS (1) 

NOTE: This form is to be used after an inquest. 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1.  The Chief Medical Officer VMD, The Veterinary Medicines Directorate, 

Veterinary Medicines Directorate, Woodham Lane, New Haw, 
Addlestone, Surrey, KT15 3LS  

2.  The Chief Executive Officer, Royal College of Veterinary Surgeons, 

Royal College of Veterinary Surgeons, 3 Waterhouse Square, 138-142 
Holborn, London EC1N 2SW 

3.  The Chief Coroner for England and Wales, Chief Coroner's Office, Room 

C09, Royal Courts of Justice, Strand, London, WC2A 2LL 

1 

CORONER 

I am Christopher Williams an Assistant Coroner, for the Coroner Area of Inner London 
South (Southwark Coroners Court). 

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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. 

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INVESTIGATION and INQUEST 

On the 22/1/2024 an investigation commenced into the death of Edward John Youde 
Barnard born 23/3/1994 and died on 9/1/2024 

The investigation concluded at the end of the inquest on 15 November 2024.  
The medical cause of death was: 

1(a) Fatal 

 overdose 

II   

My Conclusion as to the death, section 4 Record of Inquest, was “Suicide”   

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CIRCUMSTANCES OF THE DEATH 

On the 8/1/2024 Edward checked into a hotel and on the following morning he was 
found deceased in his room by a staff member. The ambulance and police services 
attended, and it was determined  that there were no suspicious circumstances. A note 
was found in the room from Edward to the hotel staff, which stated: 

“Please call 999 and report as suicide. I’m sorry I ruined your day.” 

A postmortem examination and toxicological analysis concluded that the death was 
caused by a ‘Fatal 

 overdose”. 

Edward had a history of anxiety and depression and had attended Cognitive 
Behaviour Therapy counselling in 2018 he also had a heart defect which was 
operated in 2021 which had a detrimental effect on his mental well-being.  

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 I concluded that he took the 
after he checked into the hotel room. 

, with the clear intention of ending his life, 

The toxicology report recorded a 
fatal level was 

 ug/ml. 

 blood level of 

 ug/ml and noted the 

The toxicology report went on to state  that 
barbiturate used in the UK only as an anaesthetic agent in Veterinary Medicine. 

 was a short acting 

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CORONER’S CONCERNS 

From the evidence I received, at the inquest, there are 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.  –  

On completion of the inquest, I was concerned that Edward, a vulnerable young adult, 
, a substance which I understand 
managed to come into possession of 
from the Toxicology report, is only licensed for use on animals by qualified veterinary 
professionals.  I infer from the Toxicology evidence and the fact that Edward was not 
a veterinary professional that he must have obtained the substance from an illicit 
source. I am concerned that if I do not make a report a potential emerging risk to life 
may slip past public attention unnoticed.   

I therefore make this report to the Veterinary Medicines Directorate, whom I 
understand is the organisation responsible for licensing 
Directorate is aware that the drug has been used for a suicidal purpose and to enable 
the organisation to examine any available preventive measures to reduce the risk of 
this suicide method occurring in future. 

, so that the 

I am also reporting this fatal incident to the Royal Society of Veterinary Surgeons to 
share the information with its members and to ensure that those to whom the drug is 
licensed  are made fully aware of its potential to be used in the completion of suicide 
by humans. I also make the report to the Royal Society to take  any available 
preventive measures to reduce the risk of this suicide method in future. 

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ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe your 
organisations have the power to take such action.  

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YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by the 16th January 2025. I, the coroner, may extend the period on request. 

Your responses 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. 

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COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested 
Persons who may find it useful or of interest: 

-  The family of Edward John Youde Barnard 

I am also under a duty to send the Chief Coroner a copy of your response.  

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 The Chief Coroner may publish either or both in a complete or redacted or summary 
form. She may send a copy of this report to any person who she 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. 

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Dated: 

 Signed: 

 21st November 2024

 Christopher Williams 

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RCVS response to Coroner’s Regulation 28 report in respect of Edward John Youde 
Barnard 

Introduction 

1.  Firstly, having read about the tragic circumstances of his death, we wish to express our deep 

condolences to Mr Barnard’s family and friends at what must be a very difficult time. 

2.  Prior to receiving the Regulation 28 report (‘the report’), we were unaware of Mr Barnard’s 

death or his use of pentobarbital. As you know, the RCVS was not called to give evidence at 
the inquiry nor were we invited to attend. Furthermore, we have not had access to a transcript 
or recording of the proceedings. As such, our below response is based solely on the report.  

3.  We wish to thank the Assistant Coroner for highlighting the issues in this case relevant to the 

veterinary profession and for the opportunity to provide the following comments and 
information. 

Background 

4.  Before moving on to the specific issues raised regarding veterinary medicines, it may be of 

assistance to set out some background. Whilst research suggests that suicidal ideation is not 
higher in the veterinary profession as compared to the general population, the likelihood of 
completion is higher due to knowledge of, and access to, lethal means. Prevention and 
reduction of suicide in the veterinary professions has therefore been an area of focus in many 
aspects of our work in recent years, and naturally increased safeguards around veterinary 
medicines used for euthanasia have been a key part of this work. As such, whilst Mr Barnard 
was not a veterinary surgeon or veterinary nurse himself, we believe our ongoing work is 
relevant to the issues raised in this inquiry. 

Veterinary medicines 

5. 

It should be noted that many of the requirements around controlled drugs (CDs), regardless of 
whether they are licensed for human or veterinary use, are set out in the Misuse of Drugs Act 
1971, the Misuse of Drugs Regulations 2001 and the Misuse of Drugs (Safe Custody) 
Regulations 1973. As you will know, the Home Office is the relevant government department 
with responsibility for this legislation.  

6.  From the information we have, it is unclear how Mr Barnard obtained the 

 used 
to end his life and so we are unable to comment on the specifics of this case. However, the 
following information outlines some of the relevant guidance in respect of veterinary 
medicines, and specifically in relation to CDs. 

7. 

In light of the known risk factors, the RCVS consistently goes beyond what is required by 
legislation with the aim of reducing misuse of drugs, including CDs. For example, although 
quinalbarbitone (aka Somulose) is a schedule 2 controlled drug (CD), it is exempted from 
‘safe custody’ (specific requirements for safe storage of certain CDs) in the legislation despite 
the risk it poses to human life if misused. In February 2023, we therefore issued guidance 
requiring that veterinary surgeons and veterinary nurses lock quinalbarbitone away in a 
manner equivalent to ‘safe custody’. Similarly, the barbiturates (including 
schedule 3 CDs and as such, not subject to safe custody under the relevant legislation. 
Again, in 2021 we issued guidance requiring veterinary surgeons and veterinary nurses to 
securely lock them away. 

) are 

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 8. 

In addition, we advise that, wherever possible, CDs should be returned to the CD cabinet at 
the practice for storage overnight. (See Practice Standards Scheme standards, 10.1.12 (small 
animal), 8.1.12 (farm animal), 9.1.12 (equine)). As well as restricting access by veterinary 
surgeons when they are not on duty, this guidance aims to reduce the risk of drugs being 
stolen from vehicles and entering the illegal market. 

9.  As you may be aware, sale and supply of veterinary medicines is tightly controlled under the 
Veterinary Medicines Regulations 2013 (as amended) (VMR), and the Veterinary Medicines 
Directorate (VMD) gives guidance on how those regulations should be applied. The following 
non-exhaustive list is demonstrative of the restrictions in place: 

a.  Only a holder of a manufacturing authorisation or a wholesale dealer’s authorisation 

granted by the Secretary of State may supply veterinary medicinal products wholesale, or 
be in possession of it for that purpose. 

b.  Wholesalers may only deliver veterinary medicinal products to registered premises. 

c.  Prescription-only veterinary medicines (POM-Vs) – which includes CDs of all schedules - 
may only be supplied by a veterinary practice (or a pharmacist) in accordance with a 
prescription from a veterinary surgeon (although the VMR does allow practices to supply 
other practices with medicines ‘for the purpose of alleviating a temporary supply shortage 
that could be detrimental to animal welfare’). 

10.  In addition to the requirements set out by the RCVS and VMD, the veterinary profession itself 

is also working to reduce use of veterinary medicines in suicide. Innovations such as 
Euthasafe, a storage box requiring two-factor authentication and additional information to be 
provided before allowing access to the lethal medicines inside, is one such example.  

Proposed actions and timetable 

11.  As required by the report, we have reviewed the existing measures in place to prevent future 

deaths and assessed what more could be done. We also note the Assistant Coroner’s 
comment as follows: 

‘I am also reporting this fatal incident to the Royal Society of Veterinary Surgeons [sic] to 
share the information with its members and to ensure that those to whom the drug is licensed 
are made fully aware of its potential to be used in the completion of suicide by humans. I also 
make the report to the Royal Society [sic] to take any available preventive measures to 
reduce the risk of this suicide method in future.’ 

12.  In light of the above, the actions set out in the table below have been agreed. 

Action 

1  Relevant RCVS committees to consider additional Core requirement(s) in 
the RCVS Practice Standards Scheme for practices to have individualised 
suicide prevention plans. The aim being to prevent incidents and protect 
staff and the wider public. 

Date  
February 2025 

2  RCVS Standards Committee to review the legislative requirements for 

February 2025 

schedule 2 CDs and decide what (if any) provisions may be extended to 
schedule 3 CDs via RCVS guidance, for example, requirement to record 
use in the CD register. 

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 Action 

3  RCVS Standards Committee to review the guidance on returning CDs to the 

practice when off duty. 

4  Explore methods of communicating the legal and regulatory requirements 
relating to lethal medicines to the profession (e.g. via RCVS Academy, the 
RCVS online continuing professional development portal), including 
signposting to advisory/support services. 

Date  
February 2025 

Spring 2025 

5  Continue to engage with the Home Office in respect of implementing 

Ongoing 

additional safeguards for controlled drugs used for euthanasia in veterinary 
medicine. 

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