Frederick Ireland-Rose
PFD Report
All Responded
Ref: 2025-0286
All 2 responses received
· Deadline: 1 Aug 2025
Response Status
Responses
2 of 2
56-Day Deadline
1 Aug 2025
All responses received
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
(1) The use of nitazenes as an adulterant to street heroin is well known. The presence of nitazenes in vaping fluids is less well known.
(2) The level of nitazenes ingested by vaping will vary enormously depending on the frequency and extent of inhalations taken by the user. Consequently, the potential risk of overdose is significant.
(3) Public health measures are in place through statutory and voluntary sector drug misuse services to inform heroin users of the risks of nitazene adulteration. Cannabinoid vape users will often not be known to drug services and therefore may not be aware of the risks posed by nitazenes in vape fluids.
(4) Drug services often issue Naloxone to be used in the event of an opiate/opioid overdose. Cannabinoid vape users may not be aware of Naloxone or may have problems accessing it.
(2) The level of nitazenes ingested by vaping will vary enormously depending on the frequency and extent of inhalations taken by the user. Consequently, the potential risk of overdose is significant.
(3) Public health measures are in place through statutory and voluntary sector drug misuse services to inform heroin users of the risks of nitazene adulteration. Cannabinoid vape users will often not be known to drug services and therefore may not be aware of the risks posed by nitazenes in vape fluids.
(4) Drug services often issue Naloxone to be used in the event of an opiate/opioid overdose. Cannabinoid vape users may not be aware of Naloxone or may have problems accessing it.
Responses
The Department of Health and Social Care (DHSC) highlights existing measures including a surveillance system for synthetic opioids and UKHSA alerts and guidance. They detail actions taken to widen naloxone availability, such as amending regulations to expand access and publishing guidance for its supply and use, with information available on the FRANK website.
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Dear Ms Bourke,
Thank you for the Regulation 28 report of 6 June 2025 sent to Professor , Chief Medical Officer at the Department of Health and Social Care (DHSC) about the death of Frederick Ireland-Rose. I am replying as the Minister with responsibility for Public Health and Prevention.
Firstly, I would like to say how saddened I was to read of the circumstances of Mr Ireland- Rose’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are deeply concerning and I am grateful to you for bringing these important matters to my attention.
The Government is taking the threat from potent synthetic drugs, including synthetic opioids such as fentanyl and nitazenes, very seriously. Drug-related deaths are tragically at record highs, and we are committed to tackling this problem through working across health, policing, and wider public services. Your report raises concerns over the presence of synthetic opioids adulterating other substances including non-opioid substances. You also raise concerns about the presence of synthetic opioids in vapes and the availability of naloxone for cannabinoid vape users.
To enable us to monitor the presence of synthetic opioids, DHSC, alongside other government departments, has a surveillance system in place which tracks changing drug markets and harms. Within this system we have established several new data streams, including collection of toxicology results from coroner post-mortem toxicology labs, and implemented a structured process for assessing the threat posed by synthetic opioids and other drugs. This process includes working closely with the Synthetic Opioids Taskforce in the Joint Combating Drugs Unit. The Synthetic Opioids Taskforce works with partner
agencies such as the National Crime Agency (NCA) and the National Police Chiefs’ Council to counter the distribution and use of dangerous substances. Additionally, the NCA, working closely with policing, Border Force and international partners has established Project HOUSEBUILDER to ensure that lines of enquiry are prioritised and vigorously pursued to stem the supply of nitazenes and other synthetic opioids to and within the UK.
Based on our long-standing surveillance, vape liquids containing nitazenes are extremely rare, with no confirmed casualties attributed. However, fake medicines containing synthetic opioids have become more common and have recently caused several deaths. This has especially been the case among people buying them online for the purpose of selfmedication. The nitazene found in Mr Ireland-Rose’s examination, n-pyrrolidino isotonitazene, is one of a number of common adulterants in fake oxycodone tablets, which are often bought online.
Where there are incidents of synthetic cannabinoids in THC vapes, the local authority public health team and the police force should act with partners to warn and protect their communities. The Government also provides funding to National Trading Standards to crack down on illegal sellers and undertake testing of products.
To further combat the threat of synthetic opioids, including their presence within fake medicines, a number of legislative changes have been implemented. On 20th March 2024, the UK controlled 15 named synthetic opioids (14 nitazenes) under Class A of the Misuse of Drugs Act 1971. Class A drugs are the most harmful substances and consequently carry the highest sentencing tariffs. Additionally, on 15th January 2025, a generic definition of nitazenes as Class A substances, became law. This aims to prevent drug gangs from trying to adjust drug recipes to attempt to bypass UK drug law. This means that anyone caught producing or supplying nitazenes could now face up to life in prison, an unlimited fine, or both. The Government will continue to take an agile approach to legislating against synthetic drugs, and we remain alert to the need for changes.
Alongside legislative changes, this Government has also published guidance for local commissioners and service providers on planning to deal with, and responding to, potent synthetic opioids. Furthermore, the report ‘Local preparedness for synthetic opioids’. provides evidence and insights for Combating Drugs Partnerships to help strengthen their preparedness for an evolving threat.
Your report also raised concerns about availability of naloxone for cannabinoid vape users. DHSC has an action plan to reduce drug and alcohol-related deaths which includes widening the availability and access to naloxone. Last year, the Government amended the Human Medicines Regulations 2012 to expand access to naloxone. The legislation means more services and professionals can supply this medication without prescription, which in turn means easier access to it for people at risk, and for their loved ones. DHSC has recently published guidance that sets out essential practical information such as who can supply naloxone, the products available, how to use naloxone and other basic lifesaving tools, and the training required.
Raising awareness of naloxone and its lifesaving potential among the general public is important. The Government has a drug and alcohol information and advice service called FRANK. This aims to reduce drug and alcohol use and their harms by providing information
and increasing awareness for young people, parents, and concerned others. The FRANK website has a page providing detailed information on when and how to use naloxone, which is available at the following link: https://www.talktofrank.com/get-help/what-to-do-in- anemergency.
There is no doubt that illicit drugs have a devastating impact on our communities. This Government will continue to respond and adapt to the changing landscape of threats caused by synthetic opioids. These harms are preventable, and this Government is committed, through our Health Mission, to ensure people live longer, healthier lives. I hope this response is helpful. Thank you for bringing these concerns to my attention.
Thank you for the Regulation 28 report of 6 June 2025 sent to Professor , Chief Medical Officer at the Department of Health and Social Care (DHSC) about the death of Frederick Ireland-Rose. I am replying as the Minister with responsibility for Public Health and Prevention.
Firstly, I would like to say how saddened I was to read of the circumstances of Mr Ireland- Rose’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are deeply concerning and I am grateful to you for bringing these important matters to my attention.
The Government is taking the threat from potent synthetic drugs, including synthetic opioids such as fentanyl and nitazenes, very seriously. Drug-related deaths are tragically at record highs, and we are committed to tackling this problem through working across health, policing, and wider public services. Your report raises concerns over the presence of synthetic opioids adulterating other substances including non-opioid substances. You also raise concerns about the presence of synthetic opioids in vapes and the availability of naloxone for cannabinoid vape users.
To enable us to monitor the presence of synthetic opioids, DHSC, alongside other government departments, has a surveillance system in place which tracks changing drug markets and harms. Within this system we have established several new data streams, including collection of toxicology results from coroner post-mortem toxicology labs, and implemented a structured process for assessing the threat posed by synthetic opioids and other drugs. This process includes working closely with the Synthetic Opioids Taskforce in the Joint Combating Drugs Unit. The Synthetic Opioids Taskforce works with partner
agencies such as the National Crime Agency (NCA) and the National Police Chiefs’ Council to counter the distribution and use of dangerous substances. Additionally, the NCA, working closely with policing, Border Force and international partners has established Project HOUSEBUILDER to ensure that lines of enquiry are prioritised and vigorously pursued to stem the supply of nitazenes and other synthetic opioids to and within the UK.
Based on our long-standing surveillance, vape liquids containing nitazenes are extremely rare, with no confirmed casualties attributed. However, fake medicines containing synthetic opioids have become more common and have recently caused several deaths. This has especially been the case among people buying them online for the purpose of selfmedication. The nitazene found in Mr Ireland-Rose’s examination, n-pyrrolidino isotonitazene, is one of a number of common adulterants in fake oxycodone tablets, which are often bought online.
Where there are incidents of synthetic cannabinoids in THC vapes, the local authority public health team and the police force should act with partners to warn and protect their communities. The Government also provides funding to National Trading Standards to crack down on illegal sellers and undertake testing of products.
To further combat the threat of synthetic opioids, including their presence within fake medicines, a number of legislative changes have been implemented. On 20th March 2024, the UK controlled 15 named synthetic opioids (14 nitazenes) under Class A of the Misuse of Drugs Act 1971. Class A drugs are the most harmful substances and consequently carry the highest sentencing tariffs. Additionally, on 15th January 2025, a generic definition of nitazenes as Class A substances, became law. This aims to prevent drug gangs from trying to adjust drug recipes to attempt to bypass UK drug law. This means that anyone caught producing or supplying nitazenes could now face up to life in prison, an unlimited fine, or both. The Government will continue to take an agile approach to legislating against synthetic drugs, and we remain alert to the need for changes.
Alongside legislative changes, this Government has also published guidance for local commissioners and service providers on planning to deal with, and responding to, potent synthetic opioids. Furthermore, the report ‘Local preparedness for synthetic opioids’. provides evidence and insights for Combating Drugs Partnerships to help strengthen their preparedness for an evolving threat.
Your report also raised concerns about availability of naloxone for cannabinoid vape users. DHSC has an action plan to reduce drug and alcohol-related deaths which includes widening the availability and access to naloxone. Last year, the Government amended the Human Medicines Regulations 2012 to expand access to naloxone. The legislation means more services and professionals can supply this medication without prescription, which in turn means easier access to it for people at risk, and for their loved ones. DHSC has recently published guidance that sets out essential practical information such as who can supply naloxone, the products available, how to use naloxone and other basic lifesaving tools, and the training required.
Raising awareness of naloxone and its lifesaving potential among the general public is important. The Government has a drug and alcohol information and advice service called FRANK. This aims to reduce drug and alcohol use and their harms by providing information
and increasing awareness for young people, parents, and concerned others. The FRANK website has a page providing detailed information on when and how to use naloxone, which is available at the following link: https://www.talktofrank.com/get-help/what-to-do-in- anemergency.
There is no doubt that illicit drugs have a devastating impact on our communities. This Government will continue to respond and adapt to the changing landscape of threats caused by synthetic opioids. These harms are preventable, and this Government is committed, through our Health Mission, to ensure people live longer, healthier lives. I hope this response is helpful. Thank you for bringing these concerns to my attention.
The Advisory Council on the Misuse of Drugs (ACMD) will raise the concerns about nitazenes in vapes at their upcoming Full Council meeting in October 2025 and with the Chair of the Novel Psychoactive Substances Committee. They note previous reports have acknowledged this issue and recommended improved toxicology and public information.
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Dear Sarah Bourke,
RE: Reg 28 Response: Frederick Ireland Rose
Thank you raising the issue of nitazenes found in vapes with the ACMD. In July 2022 the ACMD published advice on 2-benzyl benzimidazole (nitazene) and piperidine benzimidazolone opioids.
The report has been updated by the ACMD five times through a series of addendums, with a further addendum due to be published later this year:
• First addendum – December 2022
• Second addendum – October 2023
• Third addendum – December 2023
• Fourth addendum – April 2024
• Fifth addendum – November 2024.
The ACMD has a standing function to monitor emerging drugs, including new nitazenes variants and our standard operating procedure includes routes of administration within the consideration of harms. Vaping as a method of administration has also been raised as a concern in other recent ACMD reports. We have acknowledged the presence of nitazenes in vaping fluids and the need to monitor the detection of nitazenes in vapes and vaping fluid.
In the above report, it was identified that nitazenes had been found in vapes and vaping fluids. In the same report the ACMD recommended improved toxicology and testing and increased funding to achieve this (see recommendations listed in the annex). The ACMD also recommended improved information for health professionals and the general public (including people who use both opioid and non-opioid drugs) on the health effects of synthetic opioids.
I shall raise the concerns expressed in this Regulation 28 report to the Chair of the ACMD Novel Psychoactive Substances (NPS) Committee as well as at the upcoming ACMD Full Council meeting in October 2025, where members will discuss emerging issues.
I trust this provides you with assurances that the ACMD has made appropriate recommendations to the UK Government and continues to advise in this important area.
RE: Reg 28 Response: Frederick Ireland Rose
Thank you raising the issue of nitazenes found in vapes with the ACMD. In July 2022 the ACMD published advice on 2-benzyl benzimidazole (nitazene) and piperidine benzimidazolone opioids.
The report has been updated by the ACMD five times through a series of addendums, with a further addendum due to be published later this year:
• First addendum – December 2022
• Second addendum – October 2023
• Third addendum – December 2023
• Fourth addendum – April 2024
• Fifth addendum – November 2024.
The ACMD has a standing function to monitor emerging drugs, including new nitazenes variants and our standard operating procedure includes routes of administration within the consideration of harms. Vaping as a method of administration has also been raised as a concern in other recent ACMD reports. We have acknowledged the presence of nitazenes in vaping fluids and the need to monitor the detection of nitazenes in vapes and vaping fluid.
In the above report, it was identified that nitazenes had been found in vapes and vaping fluids. In the same report the ACMD recommended improved toxicology and testing and increased funding to achieve this (see recommendations listed in the annex). The ACMD also recommended improved information for health professionals and the general public (including people who use both opioid and non-opioid drugs) on the health effects of synthetic opioids.
I shall raise the concerns expressed in this Regulation 28 report to the Chair of the ACMD Novel Psychoactive Substances (NPS) Committee as well as at the upcoming ACMD Full Council meeting in October 2025, where members will discuss emerging issues.
I trust this provides you with assurances that the ACMD has made appropriate recommendations to the UK Government and continues to advise in this important area.
Report Sections
Investigation and Inquest
On 29 September 2024, Assistant Coroner Stevens commenced an investigation into the death of Frederick Ireland-Rose aged 30 years. The investigation concluded at the end of the inquest on 9 January 2025. The conclusion of the inquest was: Mr Ireland-Rose died in hospital on 19 September 2024. Prior to his death, he had taken cannabis, and some medications sourced from outside the UK. It is unclear how he came to ingest a nitazene substance or whether he knowingly did so. It is possible that the nitazene was ingested by vaping.
I returned a conclusion that Mr Ireland-Rose’s death was drug related.
The medical cause of death was: 1a Hypoxic brain injury 1b Acute opioid toxicity (N-Pyrrolidino isotonitazene).
I returned a conclusion that Mr Ireland-Rose’s death was drug related.
The medical cause of death was: 1a Hypoxic brain injury 1b Acute opioid toxicity (N-Pyrrolidino isotonitazene).
Circumstances of the Death
Mr Ireland-Rose had a history of opiate misuse. He was using cannabis and cannabinoid vapes to enable him to withdraw from opiates. He had been abstinent from opiates for about 10 days prior to his death and was well-motivated to remain opiate free. On the afternoon of 15 September 2025, Mr Ireland-Rose was found unresponsive at his home with a vape in his hand. Paramedics were called and managed to resuscitate him using advanced life support techniques. He remained unconscious and was taken to hospital. His sedation was removed soon after admission and he never regained consciousness. A CT scan of his brain demonstrated diffuse hypoxic ischaemic encephalopathy which was not compatible with extended life. Mr Ireland-Rose died in hospital on 19 September 2024.
Mr Ireland-Rose was known to purchase cannabinoid vaping fluids online from unknown sources outside the UK. Toxicology analysis found N-pyrrolidino isotonitazene at a level of 0.37 ng/ml in a sample of Mr Ireland-Rose’s blood. The Toxicologist reported that this is “a potent synthetic opioid” which is “thought to be similar or greater in potency to isotonitazene which is estimated to be approximately 20 times more potent than fentanyl”. The Toxicologist also reported that “nitazenes are illicit synthetic opioids which have recently emerged in the heroin supply in the UK”. There was no evidence to suggest that Mr Ireland-Rose had used street heroin prior to his death. The Toxicologist confirmed that nitazenes can be ingested from a vape and that they have been detected in refillable vapes and vapes bought illicitly.
Mr Ireland-Rose was known to purchase cannabinoid vaping fluids online from unknown sources outside the UK. Toxicology analysis found N-pyrrolidino isotonitazene at a level of 0.37 ng/ml in a sample of Mr Ireland-Rose’s blood. The Toxicologist reported that this is “a potent synthetic opioid” which is “thought to be similar or greater in potency to isotonitazene which is estimated to be approximately 20 times more potent than fentanyl”. The Toxicologist also reported that “nitazenes are illicit synthetic opioids which have recently emerged in the heroin supply in the UK”. There was no evidence to suggest that Mr Ireland-Rose had used street heroin prior to his death. The Toxicologist confirmed that nitazenes can be ingested from a vape and that they have been detected in refillable vapes and vapes bought illicitly.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.