Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0286, written 6 Jun 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Jun 2025 |
|---|---|
| Reference | 2025-0286 |
| Deceased | Frederick Ireland-Rose |
| Coroner | Sarah Bourke |
| Coroner area | Inner North London |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Coroner ME Hassell HM Senior Coroner Inner North London REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. Drugs, 4th floor NE Quarter, Peel Building, 2 Marsham Street, London, SW1P 4DP , Advisory Council on the Misuse of , Office for Health Improvement and Disparities, Department of Health and Social Care, 39 Victoria Street, London, SW1H 0EU 1 CORONER I am Sarah Bourke, HM 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 29 September 2024, Assistant Coroner Stevens commenced an investigation into the death of Frederick Ireland-Rose aged 30 years. The investigation concluded at the end of the inquest on 9 January 2025. The conclusion of the inquest was: Mr Ireland-Rose died in hospital on 19 September 2024. Prior to his death, he had taken cannabis, and some medications sourced from outside the UK. It is unclear how he came to ingest a nitazene substance or whether he knowingly did so. It is possible that the nitazene was ingested by vaping. I returned a conclusion that Mr Ireland-Rose’s death was drug related. The medical cause of death was: 1a Hypoxic brain injury 1b Acute opioid toxicity (N-Pyrrolidino isotonitazene). 4 CIRCUMSTANCES OF THE DEATH Mr Ireland-Rose had a history of opiate misuse. He was using cannabis and cannabinoid vapes to enable him to withdraw from opiates. He had been abstinent from opiates for about 10 days prior to his death and was well- motivated to remain opiate free. On the afternoon of 15 September 2025, Mr Ireland-Rose was found unresponsive at his home with a vape in his hand. Paramedics were called and managed to resuscitate him using advanced life support techniques. He remained unconscious and was taken to hospital. His sedation was removed soon after admission and he never regained consciousness. A CT scan of his brain demonstrated diffuse hypoxic ischaemic encephalopathy which was not compatible with extended life. Mr Ireland-Rose died in hospital on 19 September 2024. Mr Ireland-Rose was known to purchase cannabinoid vaping fluids online from unknown sources outside the UK. Toxicology analysis found N-pyrrolidino isotonitazene at a level of 0.37 ng/ml in a sample of Mr Ireland-Rose’s blood. The Toxicologist reported that this is “a potent synthetic opioid” which is “thought to be similar or greater in potency to isotonitazene which is estimated to be approximately 20 times more potent than fentanyl”. The Toxicologist also reported that “nitazenes are illicit synthetic opioids which have recently emerged in the heroin supply in the UK”. There was no evidence to suggest that Mr Ireland-Rose had used street heroin prior to his death. The Toxicologist confirmed that nitazenes can be ingested from a vape and that they have been detected in refillable vapes and vapes bought illicitly. 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. – (1) The use of nitazenes as an adulterant to street heroin is well known. The presence of nitazenes in vaping fluids is less well known. (2) The level of nitazenes ingested by vaping will vary enormously depending on the frequency and extent of inhalations taken by the user. Consequently, the potential risk of overdose is significant. (3) Public health measures are in place through statutory and voluntary sector drug misuse services to inform heroin users of the risks of nitazene adulteration. Cannabinoid vape users will often not be known to drug services and therefore may not be aware of the risks posed by nitazenes in vape fluids. (4) Drug services often issue Naloxone to be used in the event of an opiate/opioid overdose. Cannabinoid vape users may not be aware of Naloxone or may have problems accessing it. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation] 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 2 August 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Family of Frederick Ireland-Rose 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. 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. 9 Sarah Bourke, HM Assistant Coroner 6 June 2025
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.
ACMD Advisory Council on the Misuse of Drugs HM Coroner Sarah Bourke Inner North London 1st Floor (NE), Peel Building 2 Marsham Street London SW1P 4DF 13th August 2025 Dear Sarah Bourke, RE: Reg 28 Response: Frederick Ireland Rose Thank you raising the issue of nitazenes found in vapes with the ACMD. In July 2022 the ACMD published advice on 2-benzyl benzimidazole (nitazene) and piperidine benzimidazolone opioids. The report has been updated by the ACMD five times through a series of addendums, with a further addendum due to be published later this year: • First addendum – December 2022 • Second addendum – October 2023 • Third addendum – December 2023 • Fourth addendum – April 2024 • Fifth addendum – November 2024. The ACMD has a standing function to monitor emerging drugs, including new nitazenes variants and our standard operating procedure includes routes of administration within the consideration of harms. Vaping as a method of administration has also been raised as a concern in other recent ACMD reports. We have acknowledged the presence of nitazenes in vaping fluids and the need to monitor the detection of nitazenes in vapes and vaping fluid. In the above report, it was identified that nitazenes had been found in vapes and vaping fluids. In the same report the ACMD recommended improved toxicology and testing and increased funding to achieve this (see recommendations listed in the annex). The ACMD also recommended improved information for health professionals and the general public (including people who use both opioid and non-opioid drugs) on the health effects of synthetic opioids. I shall raise the concerns expressed in this Regulation 28 report to the Chair of the ACMD Novel Psychoactive Substances (NPS) Committee as well as at the upcoming ACMD Full Council meeting in October 2025, where members will discuss emerging issues. I trust this provides you with assurances that the ACMD has made appropriate recommendations to the UK Government and continues to advise in this important area. Yours sincerely, Annex – Recommendations made by the ACMD on nitazenes: Recommendation 1 The following compounds should be added to Class A of the Misuse of Drugs Act 1971, consistent with the classification of other potent opioids. As these materials have no medical use it is recommended that they should be placed in schedule 1 of the Misuse of Drugs Regulations 2001 (as amended). • Metonitazene • Protonitazene Isotonitazene • • Butonitazene • Flunitazene • Metodesnitazene (metazene) • Etodesnitazene (etazene) • N-Pyrrolidino-etonitazene (etonitazepyne) • N-Piperidinyl-etonitazene (etonitazepipne) • Brorphine Lead: Home Office Measure of outcome: The inclusion of the listed compounds in Class A of the Misuse of Drugs Act 1971 and schedule 1 of the Misuse of Drugs Regulations 2001. Recommendation 2 The following compounds should be deleted from schedule 2 and added to schedule 1 of the Misuse of Drugs Regulations 2001 (as amended). • Etonitazene • Clonitazene Lead: Home Office Measure of outcome: The inclusion of the listed compounds in schedule 1 of the Misuse of Drugs Regulations 2001. Recommendation 3 The ACMD recommends that a consultation should be undertaken with stakeholders, including academia and the chemical and pharmaceutical industries on the introduction of a generic control on 2-benzyl benzimidazole variants, as new examples may be encountered and could present a serious risk of harm. Following this consultation, materials covered by the generic should be added to Class A of the Misuse of Drugs Act 1971, consistent with the classification of other potent opioids. As these materials have no medical use it is recommended that they should be placed in schedule 1 of the Misuse of Drugs Regulations 2001 (as amended). The proposed wording for the generic for addition to the Misuse of Drugs Act is as follows: [see most recent addendum published] Lead: Home Office Measure of outcome: The inclusion of the described compounds in Class A of the Misuse of Drugs Act 1971 and schedule 1 of the Misuse of Drugs Regulations 2001, following appropriate consultation. Recommendation 4 In light of the continuing emergence of NPS and particularly synthetic opioid NPS, a working group should be established to consider and provide recommendations on a UK-wide minimum standard set of post-mortem toxicology tests for apparent drug- related deaths, to include testing for relevant novel psychoactive substances to improve consistency of analysis and detection. The best practice recommendations agreed would include standards for reporting. This working group should include (but not necessarily be limited to) representation from the following: • Chief Coroner’s Office for England and Wales • Coroners Service for Northern Ireland • Crown Office and Procurator Fiscal Service Scotland • UK and Ireland Association of Forensic Toxicologists • London Toxicology Group • Faculty of Forensic and Legal Medicine • Office for Health Improvement and Disparities • Home Office Forensic Early Warning System • Police • Local drug-related deaths review partnerships • The ACMD Lead: Home Office Measure of outcome: A report detailing best practice for forensic sample analysis in the investigation of apparent drug-related deaths Recommendation 5 Adequate funding should be made available by government to allow coroners, procurators fiscal and forensic toxicologists to follow the best practice guidelines developed via Recommendation 4. Lead: Home Office Measure of outcome: Consistent and appropriate forensic analysis and reporting for suspected drug-related deaths across the UK. Recommendation 6 Information for health professionals (such as TOXBASE) and the general public (such as Frank) on the health effects of NSO should be reviewed and updated, ensuring that information is available in an appropriate format on NSO compounds including benzimidazole and piperidinyl benzimidazolone opioids and the risks that result from the inclusion of compounds of varying and sometimes very high potency in heroin preparations and counterfeit medicines. Leads: National Poisons Information Service, UK Health Security Agency, Office for Health Improvement and Disparities Measure of outcome: Information available for health professionals and the general public, including those with lived experience.
From Parliamentary Under-Secretary of State for Public Health and Prevention 39 Victoria Street London SW1H 0EU 31 July 2025 Our ref: HM Coroner Sarah Bourke Inner North London St Pancras Coroner’s Court, Camley Street, London, N1C 4PP By email: Dear Ms Bourke, , Chief Thank you for the Regulation 28 report of 6 June 2025 sent to Professor Medical Officer at the Department of Health and Social Care (DHSC) about the death of Frederick Ireland-Rose. I am replying as the Minister with responsibility for Public Health and Prevention. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Ireland- Rose’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are deeply concerning and I am grateful to you for bringing these important matters to my attention. The Government is taking the threat from potent synthetic drugs, including synthetic opioids such as fentanyl and nitazenes, very seriously. Drug-related deaths are tragically at record highs, and we are committed to tackling this problem through working across health, policing, and wider public services. Your report raises concerns over the presence of synthetic opioids adulterating other substances including non-opioid substances. You also raise concerns about the presence of synthetic opioids in vapes and the availability of naloxone for cannabinoid vape users. To enable us to monitor the presence of synthetic opioids, DHSC, alongside other government departments, has a surveillance system in place which tracks changing drug markets and harms. Within this system we have established several new data streams, including collection of toxicology results from coroner post-mortem toxicology labs, and implemented a structured process for assessing the threat posed by synthetic opioids and other drugs. This process includes working closely with the Synthetic Opioids Taskforce in the Joint Combating Drugs Unit. The Synthetic Opioids Taskforce works with partner agencies such as the National Crime Agency (NCA) and the National Police Chiefs’ Council to counter the distribution and use of dangerous substances. Additionally, the NCA, working closely with policing, Border Force and international partners has established Project HOUSEBUILDER to ensure that lines of enquiry are prioritised and vigorously pursued to stem the supply of nitazenes and other synthetic opioids to and within the UK. Based on our long-standing surveillance, vape liquids containing nitazenes are extremely rare, with no confirmed casualties attributed. However, fake medicines containing synthetic opioids have become more common and have recently caused several deaths. This has especially been the case among people buying them online for the purpose of selfmedication. The nitazene found in Mr Ireland-Rose’s examination, n-pyrrolidino isotonitazene, is one of a number of common adulterants in fake oxycodone tablets, which are often bought online. Where there are incidents of synthetic cannabinoids in THC vapes, the local authority public health team and the police force should act with partners to warn and protect their communities. The Government also provides funding to National Trading Standards to crack down on illegal sellers and undertake testing of products. To further combat the threat of synthetic opioids, including their presence within fake medicines, a number of legislative changes have been implemented. On 20th March 2024, the UK controlled 15 named synthetic opioids (14 nitazenes) under Class A of the Misuse of Drugs Act 1971. Class A drugs are the most harmful substances and consequently carry the highest sentencing tariffs. Additionally, on 15th January 2025, a generic definition of nitazenes as Class A substances, became law. This aims to prevent drug gangs from trying to adjust drug recipes to attempt to bypass UK drug law. This means that anyone caught producing or supplying nitazenes could now face up to life in prison, an unlimited fine, or both. The Government will continue to take an agile approach to legislating against synthetic drugs, and we remain alert to the need for changes. Alongside legislative changes, this Government has also published guidance for local commissioners and service providers on planning to deal with, and responding to, potent synthetic opioids. Furthermore, the report ‘Local preparedness for synthetic opioids’. provides evidence and insights for Combating Drugs Partnerships to help strengthen their preparedness for an evolving threat. Your report also raised concerns about availability of naloxone for cannabinoid vape users. DHSC has an action plan to reduce drug and alcohol-related deaths which includes widening the availability and access to naloxone. Last year, the Government amended the Human Medicines Regulations 2012 to expand access to naloxone. The legislation means more services and professionals can supply this medication without prescription, which in turn means easier access to it for people at risk, and for their loved ones. DHSC has recently published guidance that sets out essential practical information such as who can supply naloxone, the products available, how to use naloxone and other basic lifesaving tools, and the training required. Raising awareness of naloxone and its lifesaving potential among the general public is important. The Government has a drug and alcohol information and advice service called FRANK. This aims to reduce drug and alcohol use and their harms by providing information and increasing awareness for young people, parents, and concerned others. The FRANK website has a page providing detailed information on when and how to use naloxone, which link: https://www.talktofrank.com/get-help/what-to-do-in- is available at anemergency. following the There is no doubt that illicit drugs have a devastating impact on our communities. This Government will continue to respond and adapt to the changing landscape of threats caused by synthetic opioids. These harms are preventable, and this Government is committed, through our Health Mission, to ensure people live longer, healthier lives. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, PARLIAMENTARY UNDER-SECRETARY OF STATE FOR PUBLIC HEALTH AND PREVENTION
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