6 Jun 2025 Frederick Ireland-Rose · Prevention of Future Deaths report Inner North London
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Concerns raised 4 Failure to ensure cannabinoid vape users are aware of the risks posed by nitazenes in vape fluids View source Significant overdose risk from variable nitazene ingestion through vaping View source Limited awareness of nitazenes in vaping fluids View source Limited awareness of or access to Naloxone among cannabinoid vape users View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Frederick Ireland-Rose · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Frederick Ireland-Rose, who had a history of opiate misuse and had been using cannabinoid vapes, was found unresponsive at home and later died in hospital after sustaining hypoxic-ischaemic brain injury. Toxicology identified the synthetic opioid N-pyrrolidino isotonitazene, and the inquest concluded that his death was drug related. The concerns were that nitazenes in vaping fluids are less well known, vaping exposure can vary substantially with a significant overdose risk, and cannabinoid vape users may be less likely to receive information about these risks or access to Naloxone.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Advisory Council on the Misuse of Drugs; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure cannabinoid vape users are aware of the risks posed by nitazenes in vape fluids
Wider context from the report “(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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Advisory Council on the Misuse of Drugs; that does not assign responsibility.
PFD Monitor interpretation Significant overdose risk from variable nitazene ingestion through vaping
Wider context from the report “(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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Advisory Council on the Misuse of Drugs; that does not assign responsibility.
PFD Monitor interpretation Limited awareness of nitazenes in vaping fluids
Wider context from the report “(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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Advisory Council on the Misuse of Drugs; that does not assign responsibility.
PFD Monitor interpretation Limited awareness of or access to Naloxone among cannabinoid vape users
Wider context from the report “(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.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the ACMD nitazene report through five published addendums addressing emerging evidence and risks.
Verbatim wording from the response “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.” Source location Response from Advisory Council on the Misuse of Drugs
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a further addendum updating the ACMD report on nitazenes and vaping later in 2025.
Verbatim wording from the response “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:” Source location Response from Advisory Council on the Misuse of Drugs
Open published response
Concerns raised 2 Lack of restrictions on the import, export, possession or administration of oral morphine View source Failure to apply safe custody and sign-for requirements to oral morphine View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Helen Spicer · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Helen Spicer died at Royal Cornwall Hospital Truro on 4 October 2018 from an unintentional overdose of prescription morphine, against a background of opiate dependency and chronic pain due to fibromyalgia. The report raised concerns about the absence of restrictions and safe-custody requirements for oral morphine, including the lack of a requirement for collection from a community pharmacy to be signed for.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Advisory Council on the Misuse of Drugs; that does not assign responsibility.
PFD Monitor interpretation Lack of restrictions on the import, export, possession or administration of oral morphine
Wider context from the report “The absence of restrictions on the import, export, possession or administration of oral morphine , and the fact that safe custody requirements do not apply to them, including the need for them to be signed for when collecting from a community pharmacy.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Advisory Council on the Misuse of Drugs; that does not assign responsibility.
PFD Monitor interpretation Failure to apply safe custody and sign-for requirements to oral morphine
Wider context from the report “The absence of restrictions on the import, export, possession or administration of oral morphine, and the fact that safe custody requirements do not apply to them, including the need for them to be signed for when collecting from a community pharmacy .
” Open source report
Concerns raised 2 Availability of prescription drugs in vast quantities for illegal dealing to vulnerable people View source Failure to prevent prescription medication leakage from the lawful dispensing process into criminal hands View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Claire RICHARDS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Claire Richards had a history of drugs misuse and mental health issues and died at home after snorting illegally dealt pregabalin and buprenorphine, becoming unresponsive despite emergency services being summoned. The principal concern was the availability of prescription drugs in large quantities for illegal dealing to vulnerable people and the leakage of prescription medication from lawful dispensing into criminal hands.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Advisory Council on the Misuse of Drugs; that does not assign responsibility.
PFD Monitor interpretation Availability of prescription drugs in vast quantities for illegal dealing to vulnerable people
Wider context from the report “(1) This case involves a death resulting from illegally dealt prescription drugs. It is of increasing concern that prescription drugs are available in vast quantities for illegal dealing to vulnerable people .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Advisory Council on the Misuse of Drugs; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent prescription medication leakage from the lawful dispensing process into criminal hands
Wider context from the report “(1) This case involves a death resulting from illegally dealt prescription drugs. It is of increasing concern that prescription drugs are available in vast quantities for illegal dealing to vulnerable people .
(2) What steps are projected, or are actually in the pipe line, for stemming the leakage of prescription medication out of the lawful dispensing process into criminal hands ?
” Open source report
15 Aug 2016 Darren Mindham · Prevention of Future Deaths report South London
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Concerns raised 1 Lack of strict controls over access to pentobarbital View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Darren Mindham · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Darren Mindham, who worked as an assistant in a veterinary practice, removed pentobarbital from a former employer’s drugs cupboard, kept it at home, and later used it to take his life. The inquest concluded that he died from acute pentobarbital intoxication after self-administering the drug at home on 28 August 2015 while suffering from depression; the concern raised was the availability and control of pentobarbital, given its use in suicide and evidence that reducing access to means can reduce suicide rates.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Advisory Council on the Misuse of Drugs; that does not assign responsibility.
PFD Monitor interpretation Lack of strict controls over access to pentobarbital
Wider context from the report “Pentobarbital is a drug that is found in Schedule 3 of the Misuse of Drugs Regulations 2001, and is therefore not subject to the strict control found in Schedule 2 . Whilst there may be practical difficulties in complying with stricter control, the use of pentobarbital in suicide has become commonplace . It has been shown that reducing access to the means of suicide can be effective in reducing the rate of suicide .
” Open source report
13 Oct 2015 Catherine Mary Findlay · Prevention of Future Deaths report Manchester West
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Concerns raised 2 Uncontrolled internet availability of research chemicals View source Consumption of research chemicals posing potentially life-threatening danger View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Catherine Mary Findlay · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Catherine Mary Findlay, aged 37, was found unresponsive and not breathing at her home on 24 May 2015 and was pronounced dead by paramedics. The post-mortem and inquest attributed her death to Methoxyphenidine (MXP) and cocaine toxicity. The report raised concerns that MXP was freely available online as a “research chemical” despite being misused and potentially life-threatening, and requested a review of its status and control.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Advisory Council on the Misuse of Drugs; that does not assign responsibility.
PFD Monitor interpretation Uncontrolled internet availability of research chemicals
Wider context from the report “2. MXP is not a controlled substance but related to Ketamine (a dis-associative anaesthetic) and is thought to be a replacement for another substance – Methoxetomine – which is now a controlled substance under the Misuse of Drugs Act.
3. I have concerns that such substances - freely marketed as “research chemicals” are generally available over the internet . They are sold with a warning that they are not for human consumption but are misused and consumed by people and are consequently dangerous and potentially life threatening.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Advisory Council on the Misuse of Drugs; that does not assign responsibility.
PFD Monitor interpretation Consumption of research chemicals posing potentially life-threatening danger
Wider context from the report “2. MXP is not a controlled substance but related to Ketamine (a dis-associative anaesthetic) and is thought to be a replacement for another substance – Methoxetomine – which is now a controlled substance under the Misuse of Drugs Act.
3. I have concerns that such substances - freely marketed as “research chemicals” are generally available over the internet. They are sold with a warning that they are not for human consumption but are misused and consumed by people and are consequently dangerous and potentially life threatening .
” Open source report
Concerns raised 1 Availability of potent and toxic acetylfentanyl through legal marketing and the internet View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Thaker Jamal Hafid · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Thaker Jamal Hafid was found unresponsive by his wife at home on 9 February 2015 and was confirmed deceased at the scene. Post-mortem testing found Acetylfentanyl, an unlicensed and highly potent opioid that he had apparently ordered online to help wean himself off heroin; the report raised concern that its availability could lead to further deaths.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Advisory Council on the Misuse of Drugs; that does not assign responsibility.
PFD Monitor interpretation Availability of potent and toxic acetylfentanyl through legal marketing and the internet
Wider context from the report “(1) Post Mortem testing on blood taken from the deceased found the presence of Acetylfentanyl (opioid analgesic drug more potent than heroin or morphine and fentanyl) and is not licensed for medicinal use and has only been sold illegally as a “designer drug”. This drug is being marketed legally and is available over the internet. The evidence in this case indicated that the deceased had ordered it with a view to weaning himself off heroin. Such is the potency/toxicity of this drug and the apparent free availability of it, it is likely that further deaths may occur due to it’s use. It is believed that this was the first known death in the UK caused by or contributed to by this drug.
” Open source report
21 Apr 2015 Anthony Peter Kristian Garrett · Prevention of Future Deaths report Manchester West
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Concerns raised 2 Dangerous and potentially life-threatening effects of consuming synthetic cannabinoids View source Readily available synthetic cannabinoids legally and commonly sold as herbal incense View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Anthony Peter Kristian Garrett · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anthony Peter Kristian Garrett collapsed after smoking Cherry Bomb, a substance marketed as herbal incense, after drinking alcohol throughout the day. He was transported to hospital, never regained consciousness, and died the following day. The report raised concerns that synthetic cannabinoids are readily available, commonly sold as herbal incense, and can be dangerous and potentially life-threatening when misused.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Advisory Council on the Misuse of Drugs; that does not assign responsibility.
PFD Monitor interpretation Dangerous and potentially life-threatening effects of consuming synthetic cannabinoids
Wider context from the report “2. I have concerns that Synthetic Cannabinoids are readily available substances in the community, which are legally and commonly sold as herbal incense. They are sold with a warning that they are not for human consumption, but are misused and consumed by people. Consequently they can be dangerous and potentially life threatening to those who use them in this way .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Advisory Council on the Misuse of Drugs; that does not assign responsibility.
PFD Monitor interpretation Readily available synthetic cannabinoids legally and commonly sold as herbal incense
Wider context from the report “2. I have concerns that Synthetic Cannabinoids are readily available substances in the community, which are legally and commonly sold as herbal incense . They are sold with a warning that they are not for human consumption, but are misused and consumed by people . Consequently they can be dangerous and potentially life threatening to those who use them in this way.
” Open source report
9 Jun 2014 Bradley Geoffrey Michael Cockel · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1 Failure to control all NBOME chemical compounds under legislation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Bradley Geoffrey Michael Cockel · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Bradley Geoffrey Michael Cockel was found deceased on 27 April 2013 at Bramle Road, Witham. The inquest concluded drug overdose, with the medical cause recorded as 25B-NBOMe intoxication; concerns included that the drug and some related compounds were not controlled under legislation at the time.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Advisory Council on the Misuse of Drugs; that does not assign responsibility.
PFD Monitor interpretation Failure to control all NBOME chemical compounds under legislation
Wider context from the report “(1) At the time of the death this drug was not controlled and not covered by any legislation .
(2) There are several other chemical compounds of this drug.
(3) (3) NBOMEs are not currently controlled under the 1971 Misuse of Drugs Act , but as of June 2013 some, but not all of the compounds, were controlled for sale under a Temporary Banning order .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations