Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0110, written 27 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 | 27 Feb 2025 |
|---|---|
| Reference | 2025-0110 |
| Deceased | Joshua Leatham-Prosser |
| Coroner | Richard Middleton |
| Coroner area | Dorset |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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) 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 Home Secretary 1 | CORONER Tam Richard T Middleton, Assistant Coroner, for the Coroner Area of Dorset 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 the 13" June 2024, an investigation was commenced into the death of Joshua William Leatham-Prosser, born on the 5" March 1998. The investigation concluded at the end of the Inquest on the 20" February 2025. The Medical Cause of Death was: 1 (a) Urinary Sepsis (b) Severe acute on chronic cystitis and pyelonephritis (c) Chronic ketamine use The conclusion of the Inquest recorded Drug Related Death 4 | CIRCUMSTANCES OF THE DEATH Mr Leatham-Prosser had started misusing ketamine in 2019. He developed bladder problems and significant pain which then led to self medicating with ketamine for pain relief. In October 2022 he fell under the care of the urology team at University College Hospital London where he was offered surgery in October 2024. On 5/6/24, following concerns for his welfare, Mr Leatham- Prosser was found unresponsive in the hallway of his home address by paramedics. He was pronounced dead at the scene. Dorset Police investigated and found no evidence of third party involvement. RONER'S CONCERNS The MATTERS OF CONCERN are as follows: 1. During the inquest evidence was heard that: i. Mr Leatham-Prosser had started taking Cannabis as a young teenager and at the age of 17 progressed on to taking ketamine. He did not perceive this to be any more harmful than cannabis. ii. |The evidence before the inquest was that ketamine was a highly addictive drug. iii. Ketamine cystitis is an emerging epidemic in the younger population with access to this drug seemingly easy to acquire. The extremely harmful effect of this drug on the bladder is akin to acid attacks on the skin. iv. Patients seen by urologists are abusing the drug to the extent required to damage the urinary tract to the point of requiring major reconstructive surgery. The only way patients know how to relieve their symptoms is with ongoing ketamine use. A vicious cycle develops worsening the urological condition and reinforces dependence on the drug with high rates of relapse. 2. I have concerns with regard to the following: i. The highly addictive and harmful nature of a drug with a classification of Class B. ii The increasing number of young people presenting with potentially fatal health problems linked to its use. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation 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 by 24 April 2025. 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) Mr Leatham-Prosser’s family 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. Dated Signed A LA ne 4, ALA 27* February 2025 7 \ NO Richard T Middleton
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.
wd So inister of State for Policing, Fire Home Office and Crime Prevention 2 Marsham Street London SW1P 4DF www.gov.uk/home-office Mr Richard T Middleton Assistant Coroner Dorset Coroners DECS Reference: Your Reference: 25 March 2025 INQUEST INTO THE DEATH OF JOSHUA WILLIAM LEATHAM-PROSSER: REGULATION 28 REPORT Dear Mr Middleton, Thank you for your Regulation 28: Prevention of Future Deaths report of 27 February to the Home Secretary about the death of Mr Joshua William Leatham-Prosser, which you have linked to chronic ketamine use. You suggest that urgent action should be taken to prevent future deaths from ketamine. | am replying as the Minister of State for Policing, Fire and Crime Prevention. Firstly, any death related to drugs is a tragedy, and | was very sorry to read about the circumstances of Mr Leatham-Prosser’s death. | have noted that the inquest found that Mr Leatham-Prosser had used cannabis, which is controlled as a Class B drug under the Misuse of Drugs Act 1971 (‘the 1971 Act”), asa young teenager; then, he began to use ketamine, which is also controlled as a Class B under the 1971 Act, under the impression that it was no more harmful than cannabis. Further, the inquest heard that ketamine cystitis is emerging within younger populations, and that ketamine misuse can result in major reconstructive surgery. Also, | note your concerns about ketamine’s current classification as a Class B — given its addictiveness and potential of harm — and how an increasing number of young people are misusing the drug and are subsequently subject to potentially fatal health problems. | am very aware that ketamine can cause significant harm when misused, and this Government is concerned that the harms — including its degree of addictiveness and the possibility of irreversible bladder damage — may be significantly underestimated by those who use the drug. Itis also particularly worrying that the misuse of ketamine amongst young people has grown in recent times. Through the Government’s Plan for Change and mission to make our streets safer, we will continue to work closely with health, policing and wider public services to drive down drug use and its associated harms. Also, the Home Office will continue to work with our partners to discourage drug misuse and to alert people, particularly young people, about the dangers of ketamine. As you may be aware, the Government is required to consider the advice of the Advisory Council on the Misuse of Drugs (“ACMD”) before making any changes to the classification of a controlled drug. | should also like to inform you that | wrote to the Chair of the ACMD, Professor Owen Bowden-Jones, to formally commission an updated harms assessment of ketamine on 14 January. The ACMD is independent of the Government, but | have full confidence that it will consider the issue with due care and provide valuable advice. The Government will carefully consider the ACMD’s recommendations before making any decision on how to proceed. Thank you again for your letter and for bringing this matter to my attention. Yours sincerely, Minister of State for Policing, Fire and Crime Prevention
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