Kayleigh Burns: Prevention of future deaths report
Alcohol, drug and medication related deathsChild Death (from 2015)
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Date of report: 27/03/2023
Ref: 2023-0106
Deceased name: Kayleigh Burns
Coroner name: Sean McGovern
Coroner Area: Warwickshire
Category: Child Death (from 2015) | Alcohol, drugs medication related deaths
This report is being sent to: Ministry for Justice
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: The Right Honourable Mr Dominic Raab – Secretary of State for Justice. | |
| 1 | CORONER I am Sean McGovern, Senior Coroner for Warwickshire, Warwick Justice Centre, Newbold Terrace, Royal Leamington Spa, Warwickshire. |
| 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. [HYPERLINKS] |
| 3 | INVESTIGATION and INQUEST On 17 June 2022, I commenced an investigation into the death of Miss Kayleigh Burns. The investigation concluded at the end of the inquest on 24th March 2023 at Warwick Coroners Court. The medical cause of death was confirmed as 1a inhalation of Nitrous Oxide compounding Asthma. |
| 4 | CIRCUMSTANCES OF THE DEATH Miss Burns was 16 years old and suffered from asthma. On the 3rd June 2022, Kayleigh visited a friend’s flat in Stratford upon Avon. Whilst there she ingested the contents of a number of nitrous oxide cannisters. She started to wheeze and used her blue inhaler. She declined an ambulance and collapsed as she was going outside to get air. An ambulance was called and her friend performed CPR. She was resuscitated but died the next day at University Hospital Coventry & Warwickshire. The medical cause of death was inhalation of Nitrous Oxide compounding Asthma. I concluded that her death was drug related (ie inhalation of Nitrous Oxide) in the context of Asthma. |
| 5 | CORONER’S CONCERNS During the inquest, the evidence and information revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: i. Whether the present legal framework concerning Nitrous Oxide should be reviewed, in the light of this death, having regard to the seemingly increasing use of Nitrous Oxide particularly by young persons. |
| 6 | ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that 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 22nd May 2023. 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 following: 1. HHJ Teague QC the Chief Coroner of England & Wales Chief Coroner’s Office. chiefcoronersoffice@judiciary.gsi.gov.uk 2. The family of Miss Kayleigh Burns 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 other 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. |
| 9 | Sean McGovern, Senior Coroner. 27 March 2023 |