Carla James
PFD Report
Partially Responded
Ref: 2025-0072
Coroner's Concerns (AI summary)
Products are being imported and sold without adequate warnings about their highly poisonous and toxic nature, posing a serious risk to life.
View full coroner's concerns
_ are imported and sold nationally with no warnings as to the fact are highly poisonous and toxic and can endanger life.
Responses
Noted
Defra acknowledges the coroner's concerns regarding the death related to imported plant material, but states they lack legislative powers to require health warnings. They have contacted the Department for Business and Trade (DBT), who will respond separately. (AI summary)
Defra acknowledges the coroner's concerns regarding the death related to imported plant material, but states they lack legislative powers to require health warnings. They have contacted the Department for Business and Trade (DBT), who will respond separately. (AI summary)
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Dear Joanna,
Thank you for your letter of 7 February regarding the death of Carla Louise James. I was very sorry to hear about this tragic incident.
Defra is responsible for trade in regulated plants and plant material including seeds for planting. This includes responsibility for the intellectual property rights of plant breeders, plant variety registration and setting standards for marketing and certification of seed for planting and other regulated plant material. However, Defra does not have legislative powers to require health warnings, or similar, to be included when potentially hazardous plants and plant products are imported into GB.
Given this, my officials have been in touch with the Department for Business and Trade (DBT). We understand this issue is being examined by the Office for Product Safety and Standards and that they intend to write to you. It goes without saying that Defra will support the work of DBT in any way we can.
Thank you for your letter of 7 February regarding the death of Carla Louise James. I was very sorry to hear about this tragic incident.
Defra is responsible for trade in regulated plants and plant material including seeds for planting. This includes responsibility for the intellectual property rights of plant breeders, plant variety registration and setting standards for marketing and certification of seed for planting and other regulated plant material. However, Defra does not have legislative powers to require health warnings, or similar, to be included when potentially hazardous plants and plant products are imported into GB.
Given this, my officials have been in touch with the Department for Business and Trade (DBT). We understand this issue is being examined by the Office for Product Safety and Standards and that they intend to write to you. It goes without saying that Defra will support the work of DBT in any way we can.
Action Planned
The OPSS has met with Defra to discuss the regulation of toxic plants and seeds, and will continue to engage with Defra, DHSC and other stakeholders to assess if the case has wider implications for the regulation of similar products. The case will also be discussed at a cross-government suicide prevention strategy group. (AI summary)
The OPSS has met with Defra to discuss the regulation of toxic plants and seeds, and will continue to engage with Defra, DHSC and other stakeholders to assess if the case has wider implications for the regulation of similar products. The case will also be discussed at a cross-government suicide prevention strategy group. (AI summary)
View full response
Dear Ms Kearsley, Regulation 28: Prevention of Future Deaths Report Carla James Thank you for sharing your Regulation 28 Report to Prevent Future Deaths, dated 7 February 2025, following your investigation into the death of Ms Carla James, that you concluded is likely to have been caused by the deliberate ingestion of toxic . I am responding on behalf of the Department for Business and Trade, in my role as Chief Executive of the Office for Product Safety and Standards (OPSS). I was very sorry to hear of Ms James’s death. If you have the opportunity, please pass on my deepest sympathies to her family and friends. The OPSS, within the Department for Business and Trade, is the UK’s product regulator, responsible for the regulation of most consumer products, while the regulation of plants and seeds in relation to plant health and UK biosecurity is led by the Department for Environment, Food and Rural Affairs (Defra). The UK’s product safety laws require that consumer products placed on the market must be safe. In most cases, primary responsibility for ensuring that only safe consumer products are placed on the UK market lies with the producer (which can mean importer in certain circumstances). In addition, distributors of products must not supply products they know, or should know, are unsafe. I understand that the relevant product in this case was a package of natural, dried , from a species of tree native to Southeast Asia and Australasia. The product purchased by Ms James was sold by a home interiors business, as a decorative home accessory. In the absence of any sector-specific safety regulations applying to the product, it may fall to be governed under the General Product Safety Regulations 2005 (GPSR). The GPSR are broad regulations designed to ensure the safety of consumer products sold, both online and offline. They cover manufactured products, that are intended for consumers. In determining the safety of a product under the GPSR, regard is given to the presentation of the product, including its labelling and any warnings and instructions for use. If the product is within scope of the GPSR, then the producer A4
Office for Product Safety and Standards Multistory 18 The Priory Queensway Birmingham B4 6BS General enquiries: +44 (0)121 345 1201
(which can include importers) or distributor of the product should have considered the risks posed and determined whether a warning label, or other actions, would have mitigated those risks. Unfortunately, OPSS does not have any evidence regarding the product’s packaging that would enable us to determine whether such warnings were present in this case. I am aware that the high-street retailer from whom Ms James purchased the product has now stopped stocking the item. OPSS officials have discussed this case with counterparts in the Department of Health and Social Care’s (DHSC) suicide prevention team. DHSC has advised that ingestion of toxic plant products, including seeds, is a known method of suicide and they have previously sought advice from the Department’s Concerning Methods Working Group on action to address risks from plant-based toxins. This group works to raise awareness of, and prevent access to or misuse of, harmful substances. The group involves representatives from the voluntary, community and social enterprise sector, the police, the NHS, and Government departments including DBT. It gathers intelligence about methods of suicide to assess whether certain causes are prevalent or may be a growing trend. It then develops and delivers targeted actions to reduce public awareness and access to emerging methods of suicides, engaging with relevant Government departments where they may be able to help achieve this. DHSC officials have advised that this case will be discussed at the group’s next meeting, and any actions shared with OPSS. I know that you have also written to the Defra Secretary of State. OPSS has met with Defra officials to discuss the regulatory position on plants which are toxic or contain toxic seeds. They have made OPSS aware of the UK Horticultural Trade Association’s Guide to Potentially Harmful Plants, the latest version being published in 2022. It sets out guidelines for the voluntary labelling of plants (including bulbs and seeds) to inform the public of potentially harmful plants at the point of purchase and prevent unintentional ingestion. The species in this case is listed as a specialist category B plant, with the suggested labelling ‘Toxic if Eaten’. However, there are no specific legal requirements for plant labelling in relation to human safety. Going forward, OPSS will continue to engage with Defra, DHSC and other stakeholders, so that we can assess whether this tragic case has wider implications for the regulation of this or similar products in future. Thank you again for writing to OPSS on this matter. I would be grateful if you could share a copy of this letter with colleagues who may find it useful. Kind regards,
A5
Office for Product Safety and Standards Multistory 18 The Priory Queensway Birmingham B4 6BS General enquiries: +44 (0)121 345 1201
Chief Executive OPSS
A6
Office for Product Safety and Standards Multistory 18 The Priory Queensway Birmingham B4 6BS General enquiries: +44 (0)121 345 1201
(which can include importers) or distributor of the product should have considered the risks posed and determined whether a warning label, or other actions, would have mitigated those risks. Unfortunately, OPSS does not have any evidence regarding the product’s packaging that would enable us to determine whether such warnings were present in this case. I am aware that the high-street retailer from whom Ms James purchased the product has now stopped stocking the item. OPSS officials have discussed this case with counterparts in the Department of Health and Social Care’s (DHSC) suicide prevention team. DHSC has advised that ingestion of toxic plant products, including seeds, is a known method of suicide and they have previously sought advice from the Department’s Concerning Methods Working Group on action to address risks from plant-based toxins. This group works to raise awareness of, and prevent access to or misuse of, harmful substances. The group involves representatives from the voluntary, community and social enterprise sector, the police, the NHS, and Government departments including DBT. It gathers intelligence about methods of suicide to assess whether certain causes are prevalent or may be a growing trend. It then develops and delivers targeted actions to reduce public awareness and access to emerging methods of suicides, engaging with relevant Government departments where they may be able to help achieve this. DHSC officials have advised that this case will be discussed at the group’s next meeting, and any actions shared with OPSS. I know that you have also written to the Defra Secretary of State. OPSS has met with Defra officials to discuss the regulatory position on plants which are toxic or contain toxic seeds. They have made OPSS aware of the UK Horticultural Trade Association’s Guide to Potentially Harmful Plants, the latest version being published in 2022. It sets out guidelines for the voluntary labelling of plants (including bulbs and seeds) to inform the public of potentially harmful plants at the point of purchase and prevent unintentional ingestion. The species in this case is listed as a specialist category B plant, with the suggested labelling ‘Toxic if Eaten’. However, there are no specific legal requirements for plant labelling in relation to human safety. Going forward, OPSS will continue to engage with Defra, DHSC and other stakeholders, so that we can assess whether this tragic case has wider implications for the regulation of this or similar products in future. Thank you again for writing to OPSS on this matter. I would be grateful if you could share a copy of this letter with colleagues who may find it useful. Kind regards,
A5
Office for Product Safety and Standards Multistory 18 The Priory Queensway Birmingham B4 6BS General enquiries: +44 (0)121 345 1201
Chief Executive OPSS
A6
Sent To
- Department for Environment, Food and Rural Affairs
- Office for Product Safety and Standards
Response Status
Linked responses
2 of 3
56-Day Deadline
1 Apr 2025
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 19h August 2024, commenced an investigation into the death of Carla James Ms James died on the 18th August 2024 at her home address in Tottington, She was 50 years of age. Her death was unexpected and at the scene there was some evidence to suggest she may have chosen to end her life At the scene there was an indication she may have ingested from thel_ plant As a result a post mortem examination was directed together with toxicology testing: Unfortunately the mortem examination was limited due to post death changes. In December 2024 we received notification that the toxicology samples submitted were insufficient for any testing to be carried out. As a result directed a forensic botanist to examine the in order that the court had direct evidence as to what the found in the property were This report was received this week: In light of this report and investigations which have taken place over the last day am writing this Regulation 28 Prevention of Future Death report before the Inquest into the death of Carla James has been finalised.
Circumstances of the Death
Ms_James_died atuher home address Evidence on scene indicated she had A forensic botanist has examined the and has confirmed thel His is of the opinion thev are from the however both are highly toxic and ingestion of one is likely to result in death It has also been established that this product was purchased online from a local store selling home interiors_ They are widely labelled as and now appear to be available nationally in interior homeware stores as a decorative home accessory. The deceased purchased a pack of Bury. post
Enquiries have confirmed the store owners had no awareness as to the toxicity of this product and have now removed it their store They bought the same a wholesalel in Kent who imported the same from the Netherlands.
Enquiries have confirmed the store owners had no awareness as to the toxicity of this product and have now removed it their store They bought the same a wholesalel in Kent who imported the same from the Netherlands.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe each of you respectively have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.