Benn Curran-Nicholls: Prevention of future deaths report
Skip to related content
Date of report: 27/11/2023
Ref: 2023-0480
Deceased name: Benn Curran-Nicholls
Coroner name: Andrew Bridgman
Coroner Area: Manchester City
Category: Other related deaths
This report is being sent to: UK Health Security Agency | Manchester City Council
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: [REDACTED], Chief Executive, UK Health Security Agency in respect of Matter One. [REDACTED], Chief Executive, Manchester City Council in respect of Matter Two. | |
| 1 | CORONER I am Andrew Bridgman, Assistant Coroner, for the coroner area of Manchester City |
| 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 23.09.22 an investigation was opened into the death of Benn Curran-Nicholls who died on 19.09.22, aged 14 years. The investigation concluded on 13.11.23. The medical cause of death was 1a Refractory cardiogenic shock due to taxane alkaloid poisoning following ingestion of yew tree berries and leaves. 2 The conclusion was Misadventure. |
| 4 | CIRCUMSTANCES OF THE DEATH Benn Curran-Nicholls moved to Didsbury, with his family ([REDACTED]) from Australia in June 2022. Benn suffered severe autism with intellectual impairment, and daily walks in the local parks became a part of his daily routine. On the morning of 18.09.22 Benn and his father went for a walk in Fletcher Moss Park where, among other things, there was a yew tree that Benn liked to climb. Benn ate some yew tree berries and also some of the leaves. Benn’s father was not aware of the poisonous nature of yew tree berries/leaves, and so took no action. Interestingly neither was, in his evidence to me, Manchester City Council’s Neighbourhood Manager for Environmental Health aware that yew trees were poisonous. Later that day at about 6pm Benn suddenly collapsed. He was admitted to Royal Manchester Children’s Hospital by emergency ambulance where he died in the early hours of 19 September 2022. Toxicological evidence was that yew tree poisoning in humans was rare, but that a number of cases had been reported. |
| 5 | CORONER’S CONCERNS Matter One Following Benn’s death Manchester City Council contacted the UKHSA requesting consideration of public health messaging about the incident; for the risk assessment and messaging regarding yew tree berries. The UKHSA decision was conveyed to Manchester City Council by way of email dated 72.09.22. In respect to public messaging/comms the UKHSA noted a long discussion of the risk/benefit from well-intended comms. Manchester City Council were engaged in this discussion. That email setting out, among other things, “we agreed at present that there was probably a risk of doing more harm than good from any comms put out, we would be very concerned about unintended consequences from comms messages, e.g. highlighting the risk of harm which may in turn provide a source for people to self-harm as a potential route for suicide (and therefore any comms would need to be carefully considered to justify the benefit, so it certainly shouldn’t be rushed) quantifying the risk and rationalising the ned to act know would be hard to justify => we wouldn’t recommend issuing this at present on public health grounds, given the circumstances )1 case with individualised circumstances where this is not the known cause of death, and there isn’t recognised to be a heightened risk to the wider public at present) and noting the nature of the comms means that we aren’t sharing for educational/warn and inform purposes (i.e.we aren’t telling them to be alert so they don’t mistakenly consume something, in place of an edible item, we are specifically telling them not to consume something they wouldn’t usually be eating and therefore wouldn’t usually be at risk of (yew tree berries/needles/bark). We aren’t aware of yew tree poisoning being a frequent problem but if this becomes apparent, we will certainly revisit the communications”. The medical cause of death is yew tree poisoning. Yew tree poisoning is rare but is documented. The reason for not sending out comms messages for educational/warning and informational purposes because the message is about something that a person wouldn’t usually eat is illogical. Berries and the like might be attractive to young children who would not recognise the dangers and risks, of even illness let alone death. The poisonous nature of the yew tree is not, on the evidence, well known to the public. The decision appears to be focused on comms solely about the yew tree and the risks of identifying an additional means of deliberate ingestion for suicide. No consideration was given to highlighting the risks of eating wild berries and/or leaves in more general terms. In the circumstance it is my view that the decision not to put out public health messages, either specific to the yew tree or in more general terms, was not properly and fully thought through. It should be re-visited. Matter Two I was advised through the evidence of the Manchester City Council Neighbourhood Manager that Manchester City Council are in the process of carrying out a risk assessment of the yew trees in its parks, such assessment to include dangers posed by climbing etc. The outcome of such assessments was not yet known. In respect of the highly poisonous (with fatal consequences) nature of the yew tree no assessment of that specific risk is, in my view, required. There may be other trees and plants in these parks that, if any parts are eaten, risk poisoning. I heard that the assessment did not include the identification of any such trees and plants. No consideration had been given to putting up notices warning of the poisonous nature of the yew tree, and risks of eating its berries/leaves. Neither at the entrances to the parks nor at the trees themselves. Further, no consideration had been given to the posting of notices warning, in general terms rather than specifically yew trees, that, by way of example that some of the trees and plants are poisonous and may cause severe illness and perhaps death if eaten. Again, neither at the entrances and/or dotted around the parks. MATTERS OF CONCERN There is a risk of a death arising in similar circumstances, and informing the public will clearly reduce the risk of those deaths. Perhaps particularly so for a child whose carer would be so informed. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action, namely further consideration, 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 Monday 22nd January 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. I have sent a copy to Benn’s mother and father. 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 | 27/11/23 |