Victoria Storey: Prevention of future deaths report

Alcohol, drug and medication related deathsHospital Death (Clinical Procedures and medical management) related deaths

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Date of report: 30/06/2023

Ref: 2023-0222

Deceased name: Victoria Storey

Coroner name: Anna Loxton

Coroner Area: Surrey

Category: Alcohol, drug and medication related deaths | Hospital Death (Clinical Procedures and medical management) related deaths

This report is being sent to: Department of Health and Social Care and Ministry of Justice

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
 THIS REPORT IS BEING SENT TO:  
The Right Honourable Suella Braverman KC MP, Secretary of State for the Home Department
The Right Honourable Alex Chalk KC MP, Lord Chancellor and Secretary of State for Justice, Ministry of Justice,
1CORONER
Ms Anna Loxton, HM Assistant Coroner for Surrey
2CORONER’S LEGAL POWERS
I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009.
3INVESTIGATION and INQUEST
The inquest into the death of Victoria STOREY was opened on 24th January 2023. Evidence was heard and the inquest was concluded on 26th June 2023.  

I found the medical cause of death to be:
1a. Metonitazene Toxicity

I determined that Victoria took an accidental overdose of Metonidazene, a potent synthetic opioid not licensed for medicinal use. Victoria had a history of opioid dependency, exacerbated by historic necessary medicinal use and to alleviate Post Traumatic Stress Disorder following a traumatic assault aged 18. I did not find any evidence she had intended to take her own life. The source of the Metonidazene could not be traced despite Police interrogation of her electronic devices.  

I recorded a short form conclusion of Drug Related.
4CIRCUMSTANCES OF THE DEATH
Victoria was found deceased in her bedroom on the evening of 3rd September 2022. Toxicology found she had low therapeutic levels of prescribed drugs; a higher level of Venlafaxine  consistent  with  chronic  (not  acute)  dosage  and [REDACTED] of Metonitazene in her post mortem blood; which the Toxicologist stated “contributed more than minimally, and possibly substantially, to the cause of Ms  Storey’s death”. [REDACTED] containing Metonitazene were found in Victoria’s bedroom.

The Pathologist recorded a cause of death of 1a) Mixed drug (mainly Metonitazene) toxicity). Having considered the Toxicology evidence in respect of the other drugs being at low levels, save for Venlafaxine which was stated to be at a level consistent with chronic dosage, I amended the cause of death to 1a) Metonitazene Toxicity.

I heard evidence from a Drug Expert with Surrey Police that Metonitazene is not sold under that name, but is often marketed as one of the common pharmaceutical opiates, so the danger of taking this illegal substitute would not be known to the end user.
5CORONER’S CONCERNS
 
The MATTERS OF CONCERN are:
 
Victoria had a history of opioid dependency to assist with her mental health struggles. She had previously admitted to healthcare professionals purchasing illicit opioids from the internet and there was evidence of this from 2019 and 2020 on her electronic devices.

Metonitazene is illicitly traded and marketed as common pharmaceutical opiates. It has potent analgesic effects but is not approved for medicinal use due to the increased risk of adverse events.

The Home Office requested advice from the Advisory Council on the Misuse of Drugs (ACMD) on the appropriate domestic control of Metonitazene, and was advised by the ACMD on 18th July 2022 that Metonitazene (and other similar compounds) should be placed in schedule 1 of the Misuse of Drugs Regulations 2001 and listed as Class A drugs under the Misuse of Drugs Act 1971. However, at present the Act and Regulations have not been amended to include Metonitazene and it is unclear if and when this will take place. Metonitazene is not therefore currently controlled under Class A, Schedule 1, Misuse of Drugs Act 1971 despite its heroin-like effects with a high risk of fatal overdose.

Due to the nature of the trade in potent synthetic opiates, there is no way for the end user to know what the illicit substance contains.
 
Consideration should be given to whether any steps can be taken to address the above concerns.
6ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph one above have the power to take such action.
7YOUR RESPONSE
You are under a duty to respond to this report within 56 days of its date; I may extend that period on request.
 
Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed.
8COPIES
I have sent a copy of this report to the following:
1.  See names in paragraph 1 above
2. [REDACTED]
3. The Chief Coroner
 
In addition to this report, I am 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 at the time of your response, about the release or the publication of your response by the Chief Coroner.
9ANNA LOXTON
DATED this 30th day of June 2023