Stephen Myers
PFD Report
Partially Responded
Ref: 2015-0150
Coroner's Concerns (AI summary)
A product containing isopropyl nitrite, misused by inhalation, has inadequate labelling that fails to comply with current safety regulations (CLP) regarding hazards and warnings.
View full coroner's concerns
(1) Isopropyl nitrite is sold as a liquid in a small (25ml) bottle as “English Room Odoriser”. It is known that some inhale the vapour which is thought to cause a short-lived “rush” / euphoria. The label on the bottle says” do not inhale”. It is classified in accordance with 67/548/EEC: R 23: toxic by inhalation R28: very toxic if swallowed.
(2) I have received a report from West Yorkshire Analytical Services which states
“ The labelling was examined with respect to the Chemicals (Hazard Information and
Packaging for Supply) Regulations 2009 (CHIP) and the Regulation Classification, Labelling and Packaging of Substances and Mixtures 2008 (CLP) with the following observations:- Need upgrading for CLP to include the signal word “danger”. Pictograms need updating to CLP standard. Need to include the hazard statements suggested H225 Highly Flammable Liquid and Vapour, H301 Toxic if Swallowed, H331 Toxic if Inhaled. Precautionary statements suggested P210 Keep Away From Heat/Sparks/Open Flames/ Hot Surfaces – No Smoking, P261 Avoid Breathing Vapours, P301 and P310 IF SWALLOWED : Immediately call a POISON CENTRE or Doctor/Physician. The container requires a tactile warning.
(2) I have received a report from West Yorkshire Analytical Services which states
“ The labelling was examined with respect to the Chemicals (Hazard Information and
Packaging for Supply) Regulations 2009 (CHIP) and the Regulation Classification, Labelling and Packaging of Substances and Mixtures 2008 (CLP) with the following observations:- Need upgrading for CLP to include the signal word “danger”. Pictograms need updating to CLP standard. Need to include the hazard statements suggested H225 Highly Flammable Liquid and Vapour, H301 Toxic if Swallowed, H331 Toxic if Inhaled. Precautionary statements suggested P210 Keep Away From Heat/Sparks/Open Flames/ Hot Surfaces – No Smoking, P261 Avoid Breathing Vapours, P301 and P310 IF SWALLOWED : Immediately call a POISON CENTRE or Doctor/Physician. The container requires a tactile warning.
Responses
Noted
The Department for Business, Innovation and Skills clarifies that responsibility for labelling of "poppers" rests with the Health and Safety Executive and enforcement with local Trading Standards. It states that General Product Safety Regulations would not have been breached in this case as instructions for use were not followed and the Home Office tackles new psychoactive substances. (AI summary)
The Department for Business, Innovation and Skills clarifies that responsibility for labelling of "poppers" rests with the Health and Safety Executive and enforcement with local Trading Standards. It states that General Product Safety Regulations would not have been breached in this case as instructions for use were not followed and the Home Office tackles new psychoactive substances. (AI summary)
View full response
Dear Dr Hamilton, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Re: Stephen Paul Myers, deceased Ihave received your Regulation 28 Report to Prevent Future Deaths dated 21 April 2015 following your investigation and inquest into the death of Stephen Paul Myers, 49 years having drunk a bottle of poppers " isopropyl nitrite" I first say how sorry I was to hear of this tragic incident; and if you have the opportunity would you please convey my deepest sympathies to his family: You have suggested that action could be taken by this Department in order to ensure clear labelling of products poppers in an attempt to avoid repetitions of this tragic accident I should clarify that BIS is not responsible for the CHIPICLP legislation regarding the labelling of bottles of Poppers (isopropyl nitrite) This is the policy of the Health and Safety Executive: The CLP labelling on this product would depend on the concentration of isopropyl nitrite and the nature and concentration of other ingredients, and follows prescribed 'rules set under EU single market legislation. Whether Or not certain label statements such as 'If swallowed: Immediately call a Poison Centre or doctorlphysician' are used depends on the classification of the product; which is based on scientific data CLP prescribes hazard classification; labelling and packaging, and there are no provisions in CLP that restrict supply to the public 2321 - MAY 2015 aged May like
Department for Business; Innovation Skills The appropriate body with the power to enforce the requirements of CHIPICLP in the case of the labelling and other requirements of these products is the local Trading Standards Authority, in this case , Darlington. The Iocal authority Trading Standards Service will investigate whether the product was mis-labelled in accordance with CHIPICLP legislation and decide on an appropriate course of action: We are sending them copy of your report and recommendations All products intended for use by consumers are regulated under the General Product Safety Regulations (GPSR) 2005 which implements the EU's General Product Safety Directive (GPSD) This Department has responsibility for this legislation: A producer must not supply a consumer product unless it satisfies the requirement that the product is safe (regulation 5 of the General Product Safety Regulations 2005) However it appears that the instructions for use were not followed in this case. The requirement that it should be safe for its intended use would not have been breached in this case. The Home Office has responsibility for implementing the cross-Government Strategy which includes tackling new psychoactive substances (NPS), or s0 called "legal highs". The Home Office continues to take action to clamp down on the trade in NPS which has claimed the lives of too many young people. To protect the public from harm; they have controlled more than 5O0 of these substances in the past years, created the Forensic Early Warning System to identify NPS in the UK and supported law enforcement action with the latest intelligence on new substances. The Home Office has also published guidance which encourages local authorities and police forces to consider all available avenues to address supply in our communities This includes provisions in the Intoxicating Substances Supply Act 1985 which makes it an offence to supply a minor with & substance that may be inhaled (includes smoking) for the purpose of intoxication: These, and other powers, have enabled local authorities to take legal action against head seize stocks and stop the consumption of these dangerous substances. The guidance for local authorities can be found at https IwwwLov_uklgovernmentlpublicationslaction-against-head_ shops: Page 2/2 Drug five using shops,
Department for Business; Innovation Skills The appropriate body with the power to enforce the requirements of CHIPICLP in the case of the labelling and other requirements of these products is the local Trading Standards Authority, in this case , Darlington. The Iocal authority Trading Standards Service will investigate whether the product was mis-labelled in accordance with CHIPICLP legislation and decide on an appropriate course of action: We are sending them copy of your report and recommendations All products intended for use by consumers are regulated under the General Product Safety Regulations (GPSR) 2005 which implements the EU's General Product Safety Directive (GPSD) This Department has responsibility for this legislation: A producer must not supply a consumer product unless it satisfies the requirement that the product is safe (regulation 5 of the General Product Safety Regulations 2005) However it appears that the instructions for use were not followed in this case. The requirement that it should be safe for its intended use would not have been breached in this case. The Home Office has responsibility for implementing the cross-Government Strategy which includes tackling new psychoactive substances (NPS), or s0 called "legal highs". The Home Office continues to take action to clamp down on the trade in NPS which has claimed the lives of too many young people. To protect the public from harm; they have controlled more than 5O0 of these substances in the past years, created the Forensic Early Warning System to identify NPS in the UK and supported law enforcement action with the latest intelligence on new substances. The Home Office has also published guidance which encourages local authorities and police forces to consider all available avenues to address supply in our communities This includes provisions in the Intoxicating Substances Supply Act 1985 which makes it an offence to supply a minor with & substance that may be inhaled (includes smoking) for the purpose of intoxication: These, and other powers, have enabled local authorities to take legal action against head seize stocks and stop the consumption of these dangerous substances. The guidance for local authorities can be found at https IwwwLov_uklgovernmentlpublicationslaction-against-head_ shops: Page 2/2 Drug five using shops,
Sent To
- Department of Business, Innovations and Skills
Response Status
Linked responses
1 of 2
56-Day Deadline
10 Jun 2015
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 2 January 2015 I commenced an investigation into the death of Stephen Paul Myers, age 49. The investigation concluded at the end of the inquest on 13 April 2015. The conclusion of the inquest was Misadventure. The medical cause of death was: 1a) Likely Isopropyl Nitrite toxicity
2) Left Ventricular Hypertrophy and Fatty Liver.
2) Left Ventricular Hypertrophy and Fatty Liver.
Circumstances of the Death
A 49 year old man (with a background of heart disease: Left Ventricular Hypertrophy, Coronary and Valvular) was drinking in the pub on Christmas Eve (24.12.14) with friends when he drank a bottler of “Poppers” (isopropyl nitrite) which he had purchased in a local shop. He collapsed and Paramedics attempted resuscitation at the scene. He was taken to Darlington Memorial Hospital where he was pronounced dead. He had previously ingested “Poppers” without ill effects.
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.