John Ellis: Prevention of Future Deaths Report
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Date of report: 14/11/2024
Ref: 2024-0627
Deceased name: John Ellis
Coroners name: Simon Burge
Coroners Area: Hampshire, Portsmouth and Southampton
Category: Suicide (from 2015)
This report is being sent to: Royal College of Veterinary Surgeons | Veterinary Medicines Directorate
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1 Royal College of Veterinary Surgeons 2 Veterinary Medicines Directorate | |
| 1 | CORONER I am Simon BURGE, Assistant Coroner for the coroner area of Hampshire, Portsmouth and Southampton |
| 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 11 November 2022 I commenced an investigation into the death of John Robert ELLIS aged 35. The investigation concluded at the end of the inquest on 13 November 2024. The conclusion of the inquest was that: The deceased was a highly regarded young veterinary surgeon, who was experiencing difficulties in some of his personal relationships, as well as financial worries and considerable stress as a result of having recently changed jobs. On Sunday 06/11/22, he used an intravenous line to self-administer a toxic quantity of [REDACTED], which he had procured by falsely representing to his former employers that he needed it in order to euthanise a large dog. He was able to access the drug, which he knew to be dangerous, without being challenged as to its purpose. He intended to take his own life and was found deceased in the shower cubicle at [REDACTED] shortly before midnight. |
| 4 | CIRCUMSTANCES OF THE DEATH On 11 November 2022 I commenced an investigation into the death of John Robert ELLIS aged 35. The investigation concluded at the end of the inquest on 13 November 2024. The conclusion of the inquest was that: The deceased was a highly regarded young veterinary surgeon, who was experiencing difficulties in some of his personal relationships, as well as financial worries and considerable stress as a result of having recently changed jobs. On Sunday 06/11/22, he used an intravenous line to self-administer a toxic quantity of [REDACTED], which he had procured by falsely representing to his former employers that he needed it in order to euthanise a large dog. He was able to access the drug, which he knew to be dangerous, without being challenged as to its purpose. He intended to take his own life and was found deceased in the shower cubicle at [REDACTED] shortly before midnight. |
| 5 | CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) Veterinary surgeons, such as the deceased, are able to easily access potentially lethal drugs, such as [REDACTED] (which is a Schedule 3 Controlled Drug) without any adequate controls being put in place to prevent their mis-use. The deceased in this case was able to invent a story to the effect that he needed the drug in order to carry out a home visit, the purported purpose of which was to euthanise a large dog. He was given 50ml of [REDACTED] by his former employers, without any checks having first been made to verify his account of why it was needed and without scrutiny by another veterinary surgeon. He was allowed to walk out of the veterinary surgery unaccompanied, with the drug, which he then used to take his own life by means of an intravenous drip. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 January 09, 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 [REDACTED] [REDACTED] [REDACTED] [REDACTED] [REDACTED] I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 | Dated: 14/11/2024 Simon BURGE Assistant Coroner for Hampshire, Portsmouth and Southampton |