Edward Barnard
PFD Report
Partially Responded
Ref: 2024-0640
432 days overdue · 1 response outstanding
Sent To
Response Status
Responses
1 of 2
56-Day Deadline
16 Jan 2025
432 days past deadline — 1 response outstanding
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
From the evidence I received, at the inquest, there are matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. On completion of the inquest, I was concerned that Edward, a vulnerable young adult, managed to come into possession of , a substance which I understand from the Toxicology report, is only licensed for use on animals by qualified veterinary professionals. I infer from the Toxicology evidence and the fact that Edward was not a veterinary professional that he must have obtained the substance from an illicit source. I am concerned that if I do not make a report a potential emerging risk to life may slip past public attention unnoticed.
I therefore make this report to the Veterinary Medicines Directorate, whom I understand is the organisation responsible for licensing , so that the Directorate is aware that the drug has been used for a suicidal purpose and to enable the organisation to examine any available preventive measures to reduce the risk of this suicide method occurring in future.
I am also reporting this fatal incident to the Royal Society of Veterinary Surgeons to share the information with its members and to ensure that those to whom the drug is licensed are made fully aware of its potential to be used in the completion of suicide by humans. I also make the report to the Royal Society to take any available preventive measures to reduce the risk of this suicide method in future.
I therefore make this report to the Veterinary Medicines Directorate, whom I understand is the organisation responsible for licensing , so that the Directorate is aware that the drug has been used for a suicidal purpose and to enable the organisation to examine any available preventive measures to reduce the risk of this suicide method occurring in future.
I am also reporting this fatal incident to the Royal Society of Veterinary Surgeons to share the information with its members and to ensure that those to whom the drug is licensed are made fully aware of its potential to be used in the completion of suicide by humans. I also make the report to the Royal Society to take any available preventive measures to reduce the risk of this suicide method in future.
Responses
Response received
View full response
1
RCVS response to Coroner’s Regulation 28 report in respect of Edward John Youde Barnard Introduction
1. Firstly, having read about the tragic circumstances of his death, we wish to express our deep condolences to Mr Barnard’s family and friends at what must be a very difficult time.
2. Prior to receiving the Regulation 28 report (‘the report’), we were unaware of Mr Barnard’s death or his use of pentobarbital. As you know, the RCVS was not called to give evidence at the inquiry nor were we invited to attend. Furthermore, we have not had access to a transcript or recording of the proceedings. As such, our below response is based solely on the report.
3. We wish to thank the Assistant Coroner for highlighting the issues in this case relevant to the veterinary profession and for the opportunity to provide the following comments and information. Background
4. Before moving on to the specific issues raised regarding veterinary medicines, it may be of assistance to set out some background. Whilst research suggests that suicidal ideation is not higher in the veterinary profession as compared to the general population, the likelihood of completion is higher due to knowledge of, and access to, lethal means. Prevention and reduction of suicide in the veterinary professions has therefore been an area of focus in many aspects of our work in recent years, and naturally increased safeguards around veterinary medicines used for euthanasia have been a key part of this work. As such, whilst Mr Barnard was not a veterinary surgeon or veterinary nurse himself, we believe our ongoing work is relevant to the issues raised in this inquiry. Veterinary medicines
5. It should be noted that many of the requirements around controlled drugs (CDs), regardless of whether they are licensed for human or veterinary use, are set out in the Misuse of Drugs Act 1971, the Misuse of Drugs Regulations 2001 and the Misuse of Drugs (Safe Custody) Regulations 1973. As you will know, the Home Office is the relevant government department with responsibility for this legislation.
6. From the information we have, it is unclear how Mr Barnard obtained the used to end his life and so we are unable to comment on the specifics of this case. However, the following information outlines some of the relevant guidance in respect of veterinary medicines, and specifically in relation to CDs.
7. In light of the known risk factors, the RCVS consistently goes beyond what is required by legislation with the aim of reducing misuse of drugs, including CDs. For example, although quinalbarbitone (aka Somulose) is a schedule 2 controlled drug (CD), it is exempted from ‘safe custody’ (specific requirements for safe storage of certain CDs) in the legislation despite the risk it poses to human life if misused. In February 2023, we therefore issued guidance requiring that veterinary surgeons and veterinary nurses lock quinalbarbitone away in a manner equivalent to ‘safe custody’. Similarly, the barbiturates (including ) are schedule 3 CDs and as such, not subject to safe custody under the relevant legislation. Again, in 2021 we issued guidance requiring veterinary surgeons and veterinary nurses to securely lock them away.
2
8. In addition, we advise that, wherever possible, CDs should be returned to the CD cabinet at the practice for storage overnight. (See Practice Standards Scheme standards, 10.1.12 (small animal), 8.1.12 (farm animal), 9.1.12 (equine)). As well as restricting access by veterinary surgeons when they are not on duty, this guidance aims to reduce the risk of drugs being stolen from vehicles and entering the illegal market.
9. As you may be aware, sale and supply of veterinary medicines is tightly controlled under the Veterinary Medicines Regulations 2013 (as amended) (VMR), and the Veterinary Medicines Directorate (VMD) gives guidance on how those regulations should be applied. The following non-exhaustive list is demonstrative of the restrictions in place:
a. Only a holder of a manufacturing authorisation or a wholesale dealer’s authorisation granted by the Secretary of State may supply veterinary medicinal products wholesale, or be in possession of it for that purpose.
b. Wholesalers may only deliver veterinary medicinal products to registered premises.
c. Prescription-only veterinary medicines (POM-Vs) – which includes CDs of all schedules - may only be supplied by a veterinary practice (or a pharmacist) in accordance with a prescription from a veterinary surgeon (although the VMR does allow practices to supply other practices with medicines ‘for the purpose of alleviating a temporary supply shortage that could be detrimental to animal welfare’).
10. In addition to the requirements set out by the RCVS and VMD, the veterinary profession itself is also working to reduce use of veterinary medicines in suicide. Innovations such as Euthasafe, a storage box requiring two-factor authentication and additional information to be provided before allowing access to the lethal medicines inside, is one such example. Proposed actions and timetable
11. As required by the report, we have reviewed the existing measures in place to prevent future deaths and assessed what more could be done. We also note the Assistant Coroner’s comment as follows:
‘I am also reporting this fatal incident to the Royal Society of Veterinary Surgeons [sic] to share the information with its members and to ensure that those to whom the drug is licensed are made fully aware of its potential to be used in the completion of suicide by humans. I also make the report to the Royal Society [sic] to take any available preventive measures to reduce the risk of this suicide method in future.’
12. In light of the above, the actions set out in the table below have been agreed.
Action Date 1 Relevant RCVS committees to consider additional Core requirement(s) in the RCVS Practice Standards Scheme for practices to have individualised suicide prevention plans. The aim being to prevent incidents and protect staff and the wider public.
February 2025 2 RCVS Standards Committee to review the legislative requirements for schedule 2 CDs and decide what (if any) provisions may be extended to schedule 3 CDs via RCVS guidance, for example, requirement to record use in the CD register.
February 2025
3
Action Date 3 RCVS Standards Committee to review the guidance on returning CDs to the practice when off duty.
February 2025 4 Explore methods of communicating the legal and regulatory requirements relating to lethal medicines to the profession (e.g. via RCVS Academy, the RCVS online continuing professional development portal), including signposting to advisory/support services.
Spring 2025 5 Continue to engage with the Home Office in respect of implementing additional safeguards for controlled drugs used for euthanasia in veterinary medicine.
Ongoing
RCVS response to Coroner’s Regulation 28 report in respect of Edward John Youde Barnard Introduction
1. Firstly, having read about the tragic circumstances of his death, we wish to express our deep condolences to Mr Barnard’s family and friends at what must be a very difficult time.
2. Prior to receiving the Regulation 28 report (‘the report’), we were unaware of Mr Barnard’s death or his use of pentobarbital. As you know, the RCVS was not called to give evidence at the inquiry nor were we invited to attend. Furthermore, we have not had access to a transcript or recording of the proceedings. As such, our below response is based solely on the report.
3. We wish to thank the Assistant Coroner for highlighting the issues in this case relevant to the veterinary profession and for the opportunity to provide the following comments and information. Background
4. Before moving on to the specific issues raised regarding veterinary medicines, it may be of assistance to set out some background. Whilst research suggests that suicidal ideation is not higher in the veterinary profession as compared to the general population, the likelihood of completion is higher due to knowledge of, and access to, lethal means. Prevention and reduction of suicide in the veterinary professions has therefore been an area of focus in many aspects of our work in recent years, and naturally increased safeguards around veterinary medicines used for euthanasia have been a key part of this work. As such, whilst Mr Barnard was not a veterinary surgeon or veterinary nurse himself, we believe our ongoing work is relevant to the issues raised in this inquiry. Veterinary medicines
5. It should be noted that many of the requirements around controlled drugs (CDs), regardless of whether they are licensed for human or veterinary use, are set out in the Misuse of Drugs Act 1971, the Misuse of Drugs Regulations 2001 and the Misuse of Drugs (Safe Custody) Regulations 1973. As you will know, the Home Office is the relevant government department with responsibility for this legislation.
6. From the information we have, it is unclear how Mr Barnard obtained the used to end his life and so we are unable to comment on the specifics of this case. However, the following information outlines some of the relevant guidance in respect of veterinary medicines, and specifically in relation to CDs.
7. In light of the known risk factors, the RCVS consistently goes beyond what is required by legislation with the aim of reducing misuse of drugs, including CDs. For example, although quinalbarbitone (aka Somulose) is a schedule 2 controlled drug (CD), it is exempted from ‘safe custody’ (specific requirements for safe storage of certain CDs) in the legislation despite the risk it poses to human life if misused. In February 2023, we therefore issued guidance requiring that veterinary surgeons and veterinary nurses lock quinalbarbitone away in a manner equivalent to ‘safe custody’. Similarly, the barbiturates (including ) are schedule 3 CDs and as such, not subject to safe custody under the relevant legislation. Again, in 2021 we issued guidance requiring veterinary surgeons and veterinary nurses to securely lock them away.
2
8. In addition, we advise that, wherever possible, CDs should be returned to the CD cabinet at the practice for storage overnight. (See Practice Standards Scheme standards, 10.1.12 (small animal), 8.1.12 (farm animal), 9.1.12 (equine)). As well as restricting access by veterinary surgeons when they are not on duty, this guidance aims to reduce the risk of drugs being stolen from vehicles and entering the illegal market.
9. As you may be aware, sale and supply of veterinary medicines is tightly controlled under the Veterinary Medicines Regulations 2013 (as amended) (VMR), and the Veterinary Medicines Directorate (VMD) gives guidance on how those regulations should be applied. The following non-exhaustive list is demonstrative of the restrictions in place:
a. Only a holder of a manufacturing authorisation or a wholesale dealer’s authorisation granted by the Secretary of State may supply veterinary medicinal products wholesale, or be in possession of it for that purpose.
b. Wholesalers may only deliver veterinary medicinal products to registered premises.
c. Prescription-only veterinary medicines (POM-Vs) – which includes CDs of all schedules - may only be supplied by a veterinary practice (or a pharmacist) in accordance with a prescription from a veterinary surgeon (although the VMR does allow practices to supply other practices with medicines ‘for the purpose of alleviating a temporary supply shortage that could be detrimental to animal welfare’).
10. In addition to the requirements set out by the RCVS and VMD, the veterinary profession itself is also working to reduce use of veterinary medicines in suicide. Innovations such as Euthasafe, a storage box requiring two-factor authentication and additional information to be provided before allowing access to the lethal medicines inside, is one such example. Proposed actions and timetable
11. As required by the report, we have reviewed the existing measures in place to prevent future deaths and assessed what more could be done. We also note the Assistant Coroner’s comment as follows:
‘I am also reporting this fatal incident to the Royal Society of Veterinary Surgeons [sic] to share the information with its members and to ensure that those to whom the drug is licensed are made fully aware of its potential to be used in the completion of suicide by humans. I also make the report to the Royal Society [sic] to take any available preventive measures to reduce the risk of this suicide method in future.’
12. In light of the above, the actions set out in the table below have been agreed.
Action Date 1 Relevant RCVS committees to consider additional Core requirement(s) in the RCVS Practice Standards Scheme for practices to have individualised suicide prevention plans. The aim being to prevent incidents and protect staff and the wider public.
February 2025 2 RCVS Standards Committee to review the legislative requirements for schedule 2 CDs and decide what (if any) provisions may be extended to schedule 3 CDs via RCVS guidance, for example, requirement to record use in the CD register.
February 2025
3
Action Date 3 RCVS Standards Committee to review the guidance on returning CDs to the practice when off duty.
February 2025 4 Explore methods of communicating the legal and regulatory requirements relating to lethal medicines to the profession (e.g. via RCVS Academy, the RCVS online continuing professional development portal), including signposting to advisory/support services.
Spring 2025 5 Continue to engage with the Home Office in respect of implementing additional safeguards for controlled drugs used for euthanasia in veterinary medicine.
Ongoing
Report Sections
Investigation and Inquest
On the 22/1/2024 an investigation commenced into the death of Edward John Youde Barnard born 23/3/1994 and died on 9/1/2024
The investigation concluded at the end of the inquest on 15 November 2024. The medical cause of death was:
1(a) Fatal overdose
II
My Conclusion as to the death, section 4 Record of Inquest, was “Suicide”
The investigation concluded at the end of the inquest on 15 November 2024. The medical cause of death was:
1(a) Fatal overdose
II
My Conclusion as to the death, section 4 Record of Inquest, was “Suicide”
Circumstances of the Death
On the 8/1/2024 Edward checked into a hotel and on the following morning he was found deceased in his room by a staff member. The ambulance and police services attended, and it was determined that there were no suspicious circumstances. A note was found in the room from Edward to the hotel staff, which stated:
“Please call 999 and report as suicide. I’m sorry I ruined your day.”
A postmortem examination and toxicological analysis concluded that the death was caused by a ‘Fatal overdose”.
Edward had a history of anxiety and depression and had attended Cognitive Behaviour Therapy counselling in 2018 he also had a heart defect which was operated in 2021 which had a detrimental effect on his mental well-being.
“Please call 999 and report as suicide. I’m sorry I ruined your day.”
A postmortem examination and toxicological analysis concluded that the death was caused by a ‘Fatal overdose”.
Edward had a history of anxiety and depression and had attended Cognitive Behaviour Therapy counselling in 2018 he also had a heart defect which was operated in 2021 which had a detrimental effect on his mental well-being.
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.