Jack Knapman
PFD Report
All Responded
Ref: 2022-0405
All 1 response received
· Deadline: 7 Feb 2023
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56-Day Deadline
7 Feb 2023
All responses received
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Source: Courts and Tribunals Judiciary
Coroner’s Concerns
DNP is a highly toxic substance. It should never be used for human consumption. Nevertheless some people do use it to assist with weight loss and body-building. There have been many deaths associated with the use of DNP and it has been the subject of previous Prevention of Future Death Reports from coroners. The inquest heard that the number of deaths associated with the use of DNP has fallen but that the risk of further deaths remains for as long as it continues to be available and used for human consumption. The inquest was told that, following recent consultation, the Home Office intends to add DNP to the list of regulated poisons as an amendment to the Poisons Act 1972. The evidence at the inquest was that this would be a welcome action to help reduce its availability.
However, after DNP is categorised as a poison it seems that it is not clear which organisation or Department of Government should have responsibility for monitoring and preventing its sale for human consumption. This would include identification of sites offering it for sale, investigation and enforcement.
My concern is that a lack of clarity on this issue might delay an effective response to any site advertising DNP. This would clearly put lives at risk.
However, after DNP is categorised as a poison it seems that it is not clear which organisation or Department of Government should have responsibility for monitoring and preventing its sale for human consumption. This would include identification of sites offering it for sale, investigation and enforcement.
My concern is that a lack of clarity on this issue might delay an effective response to any site advertising DNP. This would clearly put lives at risk.
Responses
The Home Office has laid legislation to regulate DNP as a poison under the Poisons Act 1972, effective 1st October 2023. This will restrict sales to licensed individuals via registered pharmacists, effectively banning sales to the general public, and further work is ongoing to crack down on unlawful sales.
AI summary
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Dear Mr Barlow,
Thank you for your letter of 20 December 2022 in relation to the prevention for future deaths report following the inquest of Jack Knapman.
I am very concerned about the tragic deaths being caused by the consumption of DNP as a dieting aid. To this end, I have recently met with two bereaved families whose children tragically died from the consumption of DNP and have listened closely to their testimony. I have carefully noted the contents of your prevention of future deaths report and agree that we must do as much as possible to safeguard those who may be vulnerable to harmful sales of DNP.
As you note in your report, the Home Office has now laid legislation to regulate DNP as a poison under the Poisons Act 1972. This will mean that, from 1st October 2023, DNP can only legally be sold to a member of the public by a registered pharmacist, and then only to a member of the public with a valid explosives precursors and poisons (EPP) licence issued by the Home Office. We are not aware of any legitimate uses of DNP by the general public, and therefore this would act as an effective ban on sales to that group.
The police are responsible for enforcing the Poisons Act 1972, and therefore will be responsible for investigating unlawful sales of DNP from 1st October 2023. However, we recognise that some sellers, including those overseas, will do everything they can to flout regulations. To this end, work will remain ongoing in the Home Office and across Government to do everything we can to crack down on the unlawful sale and use of DNP by working holistically to consider all aspects of the problem.
Thank you for your letter of 20 December 2022 in relation to the prevention for future deaths report following the inquest of Jack Knapman.
I am very concerned about the tragic deaths being caused by the consumption of DNP as a dieting aid. To this end, I have recently met with two bereaved families whose children tragically died from the consumption of DNP and have listened closely to their testimony. I have carefully noted the contents of your prevention of future deaths report and agree that we must do as much as possible to safeguard those who may be vulnerable to harmful sales of DNP.
As you note in your report, the Home Office has now laid legislation to regulate DNP as a poison under the Poisons Act 1972. This will mean that, from 1st October 2023, DNP can only legally be sold to a member of the public by a registered pharmacist, and then only to a member of the public with a valid explosives precursors and poisons (EPP) licence issued by the Home Office. We are not aware of any legitimate uses of DNP by the general public, and therefore this would act as an effective ban on sales to that group.
The police are responsible for enforcing the Poisons Act 1972, and therefore will be responsible for investigating unlawful sales of DNP from 1st October 2023. However, we recognise that some sellers, including those overseas, will do everything they can to flout regulations. To this end, work will remain ongoing in the Home Office and across Government to do everything we can to crack down on the unlawful sale and use of DNP by working holistically to consider all aspects of the problem.
Report Sections
Investigation and Inquest
On 29 March 2018 I commenced an investigation into the death of Jack Knapman, age
21. The investigation concluded at the end of the inquest on 13 December 2022. The conclusion of the inquest was a narrative conclusion that Jack died as an unintended consequence of taking dinitrophenol (DNP) for weight loss and body-building.
21. The investigation concluded at the end of the inquest on 13 December 2022. The conclusion of the inquest was a narrative conclusion that Jack died as an unintended consequence of taking dinitrophenol (DNP) for weight loss and body-building.
Circumstances of the Death
1. On 21 and 22 March 2018 Jack took a substantial quantity of Dinitrophenol (DNP) for the purpose of losing weight and body-building. He developed severe toxicity and was admitted to Northampton General Hospital. Despite treatment he suffered a cardiac arrest from which he could not be resuscitated and he died shortly after 1am on 23 March 2018.
2. The inquest received evidence from the National Food Crime Unit (NFCU) and from an expert in DNP poisoning. Most of the sale of DNP is on-line. The Food Standards Agency had become aware of Jack's purchase of DNP and there was an admitted delay in sending him a letter warning of the risk, although it was not possible to conclude that this made a material difference to the outcome.
3. The evidence was that, at the time of Jack’s death, there were delays in identifying sites selling DNP, getting them taken down, obtaining lists of customers, and sending warning letters to those customers. It is important to recognise that new policies are now in place at the NFCU which provide for more effective action and timescales.
2. The inquest received evidence from the National Food Crime Unit (NFCU) and from an expert in DNP poisoning. Most of the sale of DNP is on-line. The Food Standards Agency had become aware of Jack's purchase of DNP and there was an admitted delay in sending him a letter warning of the risk, although it was not possible to conclude that this made a material difference to the outcome.
3. The evidence was that, at the time of Jack’s death, there were delays in identifying sites selling DNP, getting them taken down, obtaining lists of customers, and sending warning letters to those customers. It is important to recognise that new policies are now in place at the NFCU which provide for more effective action and timescales.
Copies Sent To
1. Mr and Mrs Knapman
2. Food Standards Agency
3. Health Security Agency
4. Northampton General Hospital
5. Northamptonshire Police
who gave evidence and may find it useful or of interest
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.