David Celino: Prevention of future deaths report
Alcohol, drug and medication related deathsChild Death (from 2015)
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Date of report: 21/08/2023
Ref: 2023-0303
Deceased name: David Celino
Coroner name: Kevin McLoughlin
Coroner Area: West Yorkshire (Eastern)
Category: Child Death (from 2015) | Alcohol, drugs medication related deaths
This report is being sent to: Festival Republic, Leeds City Council | West Yorkshire Police | Home Office | Department for Culture, Media and Sport
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: Festival Republic Ltd Leeds City Council FAO Chair of the Licensing Committee West Yorkshire Police, [REDACTED] Rt Hon Suella Braverman KC MP, Home Office, FAO Secretary of State for Home Dept. Rt Hon Secretary Lucy Frazer KC MP, of State for Culture, Media and Sport | |
| 1 | CORONER I am Kevin Mcloughlin, Senior Coroner, for the Coroner area of West Yorkshire East. |
| 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 Coroner’s (Investigations) Regulations 2013. |
| 3 | INVESTIGATION and INQUEST On 2 September 2022, I commenced an investigation into the death of David Joseph Celino aged 16. The investigation concluded at the end of the Inquest on 17 August 2023. The conclusion of the Inquest was a Narrative in which the medical cause of death was 1a Serotonin Syndrome, 1b MOMA intoxication. David Celino, aged 16, was sold tablets [REDACTED] at the Leeds Festival in August 2022. Shortly after taking [REDACTED] tablets, he developed symptoms. Despite prompt treatment, at the festival’s field hospital and in a hospital ICU, he could not be revived. |
| 4 | CIRCUMSTANCES OF THE DEATH In August 2022, large numbers of people under the age of 18 were permitted to attend the three day outdoor music event known as the Leeds Festival. This admission policy was accepted by the Leeds City Council who licence the festival and had a statutory duty to protect children from harm and prevent crime. The 2022 Crime Plan prepared by West Yorkshire Police acknowledged that the festival was targeted by gangs of criminals who seek to profit by supplying drugs to those attending. It was further acknowledged in this plan that young people under the age of 18 are likely to be naive to the risks relating to illicit drugs and hence, vulnerable to exploitation. David J Celino and his 5 friends were in this potentially vulnerable group. They had little experience of illicit drugs. They were attending a music festival for the first time without adult supervision. They were excited, having just received their GCSE results on Thursday 25 August 2022. Their parents did not have sufficient information about the availability of and/or use of drugs at the festival to make an informed assessment of the risk to their sons. David Celino bought three tablets from a drug dealer, represented to be [REDACTED]. He had no information concerning the composition of the tablets, their strength, the max dose to take (if such exists), nor the symptoms indicating an adverse reaction which should highlight the need to obtain urgent medical help. He probably took [REDACTED] tablets and began to exhibit signs of an adverse reaction within the hour. He walked around the festival site for a [REDACTED] approximately 90 minutes before collapsing and being taken to the onsite field hospital. The skilled clinicians there realised his condition may prove fatal and so after initial treatment, expedited his transfer to hospital, where he died early the next morning. |
| 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 may 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) Neither the organiser of the festival (Festival Republic) nor Leeds City Council which licenced the event had accurate information about the number of people under 18 who were attending the festival. It was estimated to be 20% of the 90,000 attending, so about 18,000. In consequence, the magnitude of the problem of potentially vulnerable, na”ive teenagers exposed to possible exploitation by drug dealers, was not appreciated. (2) It was said in the course of the evidence that some 4-5 people die annually from illicit drug related causes at the various music festivals held in Britain. It is understood that there is no governing body with oversight of music festivals and hence no record of drug related casualties, which might reveal the extent of the problem. (3) Without reliable numbers, it is not possible to interrogate the data or establish what proportion of the drug related casualties belong to the under 18 cohort of attendees. National oversight would enable comparisons to be made between different festivals and their respective demographics, as well as providing useful information as to the breadth and depth of the drug problem at different events. This in turn is likely to assist in an assessment of the effectiveness of control measures to prevent (or at least restrict) illegal drugs being brought onto festival sites. (4) The history of drug related deaths amongst teenagers at the Leeds Festival in recent years has prompted the organiser to explore a greater emphasis on deterrent measures since the 2022 festival. Unless there is a hydra headed campaign to deter illicit drugs being brought onto the festival site, I fear further deaths will occur in circumstances comparable to David Celino’s tragic death (whether involving under 18s or other age groups) in Leeds or elsewhere. There is a need to review the way sources of intelligence are harnessed and the enforcement action to be taken against anyone supplying illicit drugs, in order to convey the organiser’s determination to create a hostile environment (acting in concert with both its private security personnel and West Yorkshire Police). (5) Evidence at the inquest indicated David Celino had walked about the Leeds Festival site between approximately 7pm and 8.45pm on the evening of Saturday 27 August 2022. As the signs of his adverse drug reaction developed, he was unable to walk straight, was pale, sweating profusely and agitated. In the latter stages he needed help from two other 16-year-olds to prevent him falling over. In this period, he passed through at least one check point manned by stewards or security staff. It is likely he encountered other festival staff and/or volunteers in this period also. Lamentably, no staff or volunteers spotted the need to intervene to ask about his well-being or offer assistance. This history suggests further instruction or training for festival staff and volunteers is required as to the need to be proactive, particularly in view of the prevalence of illicit drugs and teenagers. As it was, David Celino’s friends only obtained advice as to his condition from the drug dealer they happened to encounter, who reassured them that his reaction as “normal”. (6) Various witnesses raised the issue of “Front of House” drug testing, expressing views as to the benefits and disadvantages of this being permitted. It would help all those involved in the management of events similar to the Leeds Festival to have authoritative guidance on this subject, from the Home Office, along with clarification as to exactly what is permitted. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report by Monday 13 November 2023 (the normal timescales having been extended to reflect the holiday period). 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: 1. [REDACTED] (Parents) 2. Local Safeguarding Board I have also sent it to the following individuals who may find it useful or of interest: 1. [REDACTED], Yorkshire Evening Post 2. [REDACTED], Yorkshire Live 3. [REDACTED], ITV 4. [REDACTED], PA Media 5. [REDACTED], Bauer Media 6. [REDACTED], BBC 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 | 21st August 2023 Kevin Mcloughlin |