Dear Mr Sullivan, Response_to Requlatlon 28 Report to Prevent Future_Deaths Linda Jean Baranowski deceased refer to your report following the tragic death of Linda Baranowski. On receipt of your report instigated research by Hertfordshire Trading Standards Officers to gain an initial understanding as to the availability of the products referred to in your report; and those products of a similar nature To this end a 'test purchase' was also carred out in relation t0 one similar product, and labelling issues with this product will be followed through with the appropriate local Trading Standards Service and supplier: Our research has indicated that products of a similar kind and nature to those referred to in you report are available and accessible to consumers nationwide particularly over the internet; and we therefore consider that this issue requires national, rather than local consideration and coordination, Hertfordshire Trading Standards therefore undertakes to further liaise and work with the lead national govemment agencies and regulators on the safety of food products, supplements and topical creams in examining what further can be done to address concerns in relation to the listed products. Hertfordshire Trading Standards pledges to offer input into the development of a national on this issue if required and which the Food Standards Agency (being the lead national agency on food safety matters), deems appropriate: For your information at a national level in trading standards, there is a National Trading Standards Board (which is funded Government through the Department for Business, Energy and Industrial Strategy) which amongst other things helps t0 cO-ordinate safety issues on a national basis, and the Association of Chief Trading Standards Officers, which FIRE KILLS Www_ hertfordshire gv uk DNVESTOR IN PEOPLE NouS Tradiagointt Your your strategy

also can aid the Food Standards Agency and others in co-ordinating and delivering any national approach note that one of the products; the Hot Anti-Cellulite Balo slimming cream gel chill 85ml is not a food product or supplement but a topical gel (not covered by the Food Standards Agency) , and we would welcome and encourage a coordinated approach from colleagues at a national level led by the Food Standards Agency following their Iiaison with the Medicines and Healthcare Regulatory Agency ad the Department for Business, Energy and Industrial Strategy covering general product safety in relation to such products Hertfordshire Trading Standards will respond to their direction and suggestions as they develop_

Dear Mr Sullivan, Report into the death of Mrs Linda Jean Baranowski: am writing in response to the request made under paragraph 7, schedule 5, of the Coroners and Justice Act 2009 and regulation 28 and 29 of the Coroners (Investigations) Regulations 2013 into the death of Mrs Linda Jean BARANOWSKI, dated the 22nd June 2017,and the conclusion that her death was likely caused as a result of an inflammatory response to the dietary supplements she was using in the period leading up to her death on the 25th February 2016_ regulation 28 request was also sent the Head of Community Safety Directorate for Hertfordshire Council: This response outlines specific work undertaken by the Incidents Team of the FSA in respect of Mrs Baranowski before and after her death, but also outlines the wider remit and strategic work the National Food Crime Unit is coordinating against unsafe and dangerous food for sale such as 2,4 Dintrophenol: Food Standards Agency (FSA) Incidents Team response: The FSA Incidents Team was notified on the 1st February 2016 by the Medicines and Healthcare Products Regulatory Authority (MHRA) ad Hertfordshire Trading Standards (Herts TS) that Mrs Baranowski had been admitted to hospital; We were informed she was in a critical but stable NATIONALFOOD National Food Crime Unit; Food Standards Agency_ CRIME UNIT Aviation House, 125 Kingsway, London; WCZB 6NH, The Trading the About ~tive 1 81sABL €9

condition in hospital and had been using slimming products which included TS slimming pills, White tea, green and a slimming gel. It was not known whether this list included all of the products that Mrs Baranawski had administered: At that time the hospital was not in a position to confirm what was causing the illness and, therefore, were not out any product; but it was suggested that the slimming gel might be the cause: [Note: FSA is responsible for food products; cosmetic products or anything deemed to be medicinal would come under the responsibility of the MHRA] Enquiries indicated that the products were purchased via the online selling site Ebay from Hertfordshire retailer who had been supplied by other UK suppliers: The Hertfordshire retailer contacted all of her customers to instruct them to cease using the products immediately and this was overseen by Hertfordshire Constabulary and Herts TS department Herts TS also contacted the Trading Standards departments where the UK suppliers were based. On the Znd February 2016 the FSA Incidents team conducted checks of their database for any records relating to the products, suppliers or Food Business Operators that had been notified as being involved in the production or supply of the TS slimming pills. This revealed that one of the suppliers had been the subject of a previous incident due to the presence of ephedrine, which meant the products were regarded as medicinal and would be controlled under medicines legislation. The Medical Health Regulatory Authority (MHRA) had been informed of this latest case SO we did not refer it to them for advice as we would have done otherwise_ Herts TS sought to obtain samples of the product(s) for testing, either from the hospital or from police (who had been handed some product from some f the other 39 consumers who purchased the product): The presence of the chemical 2,4 Dinitrophenol was unconfirmed and the Incidents team were content that the local Trading Standards (and police) had acted promptly and appropriately to reduce risk to others who had bought the package of products. This remained an apparent safety issue of undetermined causality and we had no further information on which to act_ On the 17th March 2016, having requested an update, the Incidents Team were informed by Herts TS that they consumer had died several weeks before and that Hertfordshire Constabulary were investigating the circumstances around the death: Herts TS were awaiting information on the cause of death but had analysed some of the same slimming tablets that had been supplied by the same retailer for 2,4 Dinitrophenol (DNP), a dangerous chemical that has been used as a slimming pill but is not intended for human ingestion: FSA were advised that DNP had not been detected, and are awaiting the quantitative analysis of HCA_ also had some slimming gel analysed for DNP but this was not found to be present either. The Incidents team were informed that Herts TS had made some follow up enquiries and taken the products off but noted some were still available elsewhere (e.&. Amazon)_ On the 19th April 2016 FSA Incidents contacted Herts TS to seek an update on the cause of death and any further information (such a5 results for some further tablets that were being tested) and were informed that there was no further information available We have been notified by Herts TS of the following specific samples tested as part of their investigation: NATIONAL FOOD National Food Crime Unit; Food Standards Agency, CRIME UNIT Aviation House, 125 Kingsway, London, WCZB 6NH. tea, ruling Ebay the The They EBay Abour 1 O15ABL *9

TS Garcinia Extreme Tablets (TS sample number 01625) Green and White Tea Bags TS sample numbers 01623 & 01624 (received from Herts police, original supplier no product left) Hot Yili Balo Body Slimming Gel (TS Sample number S56098) Balo Chilli gel (TS Sample number S56099} Chilli Gel (TS sample number S560100) The samples were all sent to the Public Analyst to test for the presence of DNP (It is a breach of general food law to sell this for human consumption) the ingredients and labelling for compliance with the General Product Safety Regulations 2005, Cosmetic Product Enforcement Regulations 2013 and the Food Safety Act 1990. Sample numbers 01623 and 01624 Green & White Teabags could not be analysed due to cross contamination and all mixed up in the same bag: Sample 01625 TS Garcinia Extreme Fat Burner was compliant with regards to DNP- No DNP was detected_ No other safety issues to be investigated by Trading Standards_ Sample Number S56098 Hot Yili Balo Body Slimming Gel It is the Public Analyst opinion it was not a Cosmetic Product. There was no DNP detected_ Sample Number S56099 Hot Yili Balo Body Slimming Gel It is the Public Analyst opinion was not a Cosmetic Product, There was no DNP detected_ Sample Number S56100 Hot Yili Balo Body Slimming Gel It is the Public Analyst opinion it was not a Cosmetic Product: There was no DNP detected_ NFCU Activity The NFCU continues to take steps to tackle the marketing and sale of 2,4 dinitrophenol (DNP): Owing to the dangers posed to the public tackling the illegal sale of DNP is one of the unit's highest priorities and will continue to be so. Whilst we have had some success in this area and there are encouraging signs that this is beginning to have a deterrent effect on both suppliers and potential users of the chemical there is still work to be done and we will continue to direct resource at this issue Figures on cases of DNP toxicity in the UK are compiled by the National Poisons Information Service (NPIS): The NPIS the UK Department of Health approved, and Public Health England commissioned , national service that provides expert advice on all aspects of acute and chronic poisoning In 2016, fourteen cases of DNP poisoning were reported, resulting in one fatality: This is in comparison to 2015 during which there were thirty-five cases reported with six fatalities. The NPIS data shows steady decline in TOXBASEI access and telephone enquiries to the NPIS since the second quarter of 2015. The decline in reported cases and enquiries of NPIS corresponds with the NFCU targeted operation against the sale of DNP for human consumption: The NFCU is aware of only one UK death from DNP toxicity in 2016,and have been informed of a further death in February 2017 and inquiries continue into the circumstances of this fatality: The database by which health practitioners find infomation on toxins NATIONALFOOD National Food Crime Unit; Food Standards Agency; CRIME UNIT Aviation House, 125 Kingsway; London, WCZB 6NH. being Bour 0 0 OgsABI 6

The NFCU has continued to promote the #dnpkills message on social media, most recently with the launch of pictorial e-cards warning the public of the dangers of DNP. Press releases have also been issued along with information on the FSA website Much of the market for DNP is via the internet which brings its own set of challenges, especially as most of the websites are neither hosted nor operated from within the UK. Nonetheless the NFCU is actively seeking opportunities to make interventions including regular monitoring of the internet to identify those websites selling DNP_ Please do not hesitate to contact me if you require any further information: