Dear Mr Bridgman Re: Ref 2023-0480, Regulation 28 report to prevent future deaths Thank you for the prevention of future deaths report sent to UK Health Security Agency (UKHSA) on 27 November 2023. Firstly, I would like to offer my sincere condolences on behalf of UKHSA to the family of Benn Curran-Nicolls who tragically died following ingestion of yew tree berries. The concerns raised in the report have been considered and reflected upon by UKHSA and its response is below. UKHSA notes that two matters of concern were raised in the Regulation 28 report. This response addresses “Matter One” only, as “Matter Two” is for Manchester City Council. UKHSA provide scientific and operational leadership, working with local, national and international partners to protect the public’s health and build the nation’s health security capability. We risk assess and take public health action including identification of source of risk and mitigation to prevent onward transmission or further harm to the public for infectious diseases and environmental issues. We work closely with a wide range of local partners including local authorities to investigate, and prevent the risk. As part of this, we communicate with the public directly, or via our partner agencies, regarding threats from infectious disease and the environment, where it is proportionate to the risk to public health and where messaging has clear actions for the public. Response to Matter One (issuing communications to the public with respect to not ingesting yew tree berries, leaves or bark) Manchester City Council were contacted by Greater Manchester Police to request consideration of proportionate messaging to be disseminated to the public. Manchester City 1

Council contacted UKHSA on 26 September 2023 requesting UKHSA to consider any messaging alongside Environmental Health and Public Health Colleagues in the Council. UKHSA public health specialist and environmental public health scientists and Manchester City Council Public Health and environmental health colleagues undertook a full risk assessment on 27 September 2023, and followed up with an email on the same date summarising the agreed position. The decision not to issue public health messaging was a joint decision between UKHSA and Manchester City Council and was made following wider discussions with key specialists between the two agencies. UKHSA have reviewed the advice provided to Manchester City Council at the time. For the reasons below, UKHSA maintains that the decision not to put out public health messages in respect of ingestion of plants, or yew tree specifically was appropriate. UKHSA respectfully disagrees that the decision “was not properly and fully thought through”. The decision was proportionate based on the assessment of risk and consideration of the utility and impact of any messaging. Assessment of risk of harm Death from toxic effect of ingested plants is very rare. The most recent data available from Office of National Statistics (2016) identifies six deaths from ingestion of plants in England and Wales1. Of these deaths, 4 were suicides, one ingestion was accidental and it was unclear whether the remaining case was accidental or suicide. Yew tree poisoning (Taxus baccata intoxication) is described in medical literature as a known poison that can lead to death. One publication reports 22 documented case studies between 1960 and August 20162. Of the 22 cases, 15 were suicides and one ingestion was accidental. It was unclear whether the 6 remaining cases were accidental or suicides. As per our previous advice provided to the Council, we maintain that there is a greater risk of doing harm than good by proactively sharing messaging with the general public to not ingest plants, or specifically yew tree, as there is a risk of unintended consequences from such messages, where it highlights the risk of harm which may in turn provide a source for people to self-harm as a potential route for suicide. 1 Number of deaths from toxic effect of ingested plants, by underlying cause, England and Wales, deaths registered in 2016 - Office for National Statistics (ons.gov.uk) 2 Guido Reijnen, Corine Bethlehem, Jacquo M.B.L. van Remmen, Hans J.M. Smit, Matthijs van Luin, Udo J.L. Reijnders. Post-mortem findings in 22 fatal Taxus baccata intoxications and a possible solution to its detection, Journal of Forensic and Legal Medicine. Volume 52, 2017, Pages 56-61, ISSN 1752-928X,

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Given the rarity of the issue, and that it is not possible to issue messaging which has clear actions for the public, public health communication is not deemed appropriate and has the potential to lead to unintended consequences. Action taken and proposed action In addition to revisiting the advice and risk assessment referred to above, UKHSA have highlighted the risk of ingesting yew tree berries across its partner agencies as follows:
- On 7 December 2023, UKHSA North West highlighted the report to prevent future deaths and associated risk to all 24 Directors of Public Health across the NW verbally and in a presentation. As a result, Directors of Public Health were asked to consider whether any additional action should be undertaken in parks and open spaces within their local authority areas, as was highlighted to Manchester City Council. In addition, some general resources were shared with Directors of Public Health that can be shared with their residents as required (https://www.rhs.org.uk/prevention­ protection/potentially-harmful-garden-plants,

- On 20 December, UKHSA North West highlighted the report to prevent future deaths and associated risk to the other eight English regions within UKHSA and with the Devolved Administrations to highlight the potential risk. Thank you for bringing this matter to my attention.