Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0072, written 4 Feb 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Feb 2025 |
|---|---|
| Reference | 2025-0072 |
| Deceased | Carla James |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester North |
| Category | Suicide (from 2015) · Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. En, Minister for Employment Rights, Competition and Markets, c/o Office for Product Safety and Standards. 2: Po Secretary of State for Environment, Food and Rural Affairs CORONER | am Joanne Kearsley, Senior Coroner for the Coroner area of Manchester North CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 INVESTIGATION and INQUEST On the 19" August 2024, | commenced an investigation into the death of Carla James. Ms James died on the 18" August 2024 at her home address in Tottington, Bury. She was 50 years of age. Her death was unexpected and at the scene there was some evidence to suggest she ma have chosen to end her life. At the scene there was an indication she may have ingested from the RE plant. As a result a post mortem examination was directed together with toxicology testing. Unfortunately the post mortem examination was limited due to post death changes. In December 2024 we received notification that the toxicology samples submitted were insufficient for any testing to be carried out. As a result | directed a forensic botanist to examine the || in order that the court had direct evidence as to what the found in the property were. This report was received this week. In light of this report and investigations which have taken place over the last day | am writing this Regulation 28 Prevention of Future Death report before the Inquest into the death of Carla James has been finalised. CIRCUMSTANCES OF DEATH nl address. Evidence on scene indicated she hac A forensic botanist has examined the HB anc has _ confirmed the} His is of the opinion they are from the however both are highly toxic and ingestion of cna likely to result in death. It has also been established that this product was purchased online from a local store selling home interiors. They are widely labelled ae now appear to be available nationall in interior homeware stores as a decorative home accessory. The deceased purchased a pack of Enquiries have confirmed the store owners had no awareness as to the toxicity of this product and have now removed it from their store. They bought the same from a wholesale] in Kent who imported the same from the Netherlands. CORONER’S CONCERNS During the course of the investigation 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:- 1. TEE 2:6 being imported and sold nationally with no warnings as to the fact they are highly poisonous and toxic and can endanger life. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe each of you respectively have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 7% April 2025 |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- The family of Ms James | 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 from. 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. Date: 7-2-2005 sonal foAISa4
2 responses 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.
Secretary of State Environment, Food & Rural Affairs
Seacole Building
2 Marsham Street
London
SW1P 4DF
T: +44 (0) 3459 335577
E: correspondence.section@defra.gov.uk
W: gov.uk/defra
Your ref:
Our ref:
4 March 2025
Ms J Kearsley
HM Senior Coroner
Greater Manchester North
HM Coroner's Court
Floors 2 & 3
Newgate House, Newgate
Rochdale, OL16 1AT
Dear Joanna,
Thank you for your letter of 7 February regarding the death of Carla Louise James. I was
very sorry to hear about this tragic incident.
Defra is responsible for trade in regulated plants and plant material including seeds for
planting. This includes responsibility for the intellectual property rights of plant breeders,
plant variety registration and setting standards for marketing and certification of seed for
planting and other regulated plant material. However, Defra does not have legislative
powers to require health warnings, or similar, to be included when potentially hazardous
plants and plant products are imported into GB.
Given this, my officials have been in touch with the Department for Business and Trade
(DBT). We understand this issue is being examined by the Office for Product Safety and
Standards and that they intend to write to you. It goes without saying that Defra will support
the work of DBT in any way we can.
Yours sincerely,
A3
Office for Product Safety and Standards Multistory 18 The Priory Queensway Birmingham B4 6BS General enquiries: +44 (0)121 345 1201 07 April 2025 Joanne Kearsley Deputy Chief Coroner of England and Wales Senior Coroner, Manchester North HM Coroner’s Court Newgate House Dear Ms Kearsley, Regulation 28: Prevention of Future Deaths Report Carla James Thank you for sharing your Regulation 28 Report to Prevent Future Deaths, dated 7 February 2025, following your investigation into the death of Ms Carla James, that you concluded is likely to have been caused by the deliberate ingestion of toxic . I am responding on behalf of the Department for Business and Trade, in my role as Chief Executive of the Office for Product Safety and Standards (OPSS). I was very sorry to hear of Ms James’s death. If you have the opportunity, please pass on my deepest sympathies to her family and friends. The OPSS, within the Department for Business and Trade, is the UK’s product regulator, responsible for the regulation of most consumer products, while the regulation of plants and seeds in relation to plant health and UK biosecurity is led by the Department for Environment, Food and Rural Affairs (Defra). The UK’s product safety laws require that consumer products placed on the market must be safe. In most cases, primary responsibility for ensuring that only safe consumer products are placed on the UK market lies with the producer (which can mean importer in certain circumstances). In addition, distributors of products must not supply products they know, or should know, are unsafe. I understand that the relevant product in this case was a package of natural, dried , from a species of tree native to Southeast Asia and Australasia. The product purchased by Ms James was sold by a home interiors business, as a decorative home accessory. In the absence of any sector-specific safety regulations applying to the product, it may fall to be governed under the General Product Safety Regulations 2005 (GPSR). The GPSR are broad regulations designed to ensure the safety of consumer products sold, both online and offline. They cover manufactured products, that are intended for consumers. In determining the safety of a product under the GPSR, regard is given to the presentation of the product, including its labelling and any warnings and instructions for use. If the product is within scope of the GPSR, then the producer A4 Office for Product Safety and Standards Multistory 18 The Priory Queensway Birmingham B4 6BS General enquiries: +44 (0)121 345 1201 (which can include importers) or distributor of the product should have considered the risks posed and determined whether a warning label, or other actions, would have mitigated those risks. Unfortunately, OPSS does not have any evidence regarding the product’s packaging that would enable us to determine whether such warnings were present in this case. I am aware that the high-street retailer from whom Ms James purchased the product has now stopped stocking the item. OPSS officials have discussed this case with counterparts in the Department of Health and Social Care’s (DHSC) suicide prevention team. DHSC has advised that ingestion of toxic plant products, including seeds, is a known method of suicide and they have previously sought advice from the Department’s Concerning Methods Working Group on action to address risks from plant-based toxins. This group works to raise awareness of, and prevent access to or misuse of, harmful substances. The group involves representatives from the voluntary, community and social enterprise sector, the police, the NHS, and Government departments including DBT. It gathers intelligence about methods of suicide to assess whether certain causes are prevalent or may be a growing trend. It then develops and delivers targeted actions to reduce public awareness and access to emerging methods of suicides, engaging with relevant Government departments where they may be able to help achieve this. DHSC officials have advised that this case will be discussed at the group’s next meeting, and any actions shared with OPSS. I know that you have also written to the Defra Secretary of State. OPSS has met with Defra officials to discuss the regulatory position on plants which are toxic or contain toxic seeds. They have made OPSS aware of the UK Horticultural Trade Association’s Guide to Potentially Harmful Plants, the latest version being published in 2022. It sets out guidelines for the voluntary labelling of plants (including bulbs and seeds) to inform the public of potentially harmful plants at the point of purchase and prevent unintentional ingestion. The species in this case is listed as a specialist category B plant, with the suggested labelling ‘Toxic if Eaten’. However, there are no specific legal requirements for plant labelling in relation to human safety. Going forward, OPSS will continue to engage with Defra, DHSC and other stakeholders, so that we can assess whether this tragic case has wider implications for the regulation of this or similar products in future. Thank you again for writing to OPSS on this matter. I would be grateful if you could share a copy of this letter with colleagues who may find it useful. Kind regards, A5 Office for Product Safety and Standards Multistory 18 The Priory Queensway Birmingham B4 6BS General enquiries: +44 (0)121 345 1201 Chief Executive OPSS A6
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