DAVID CHARLES MITCHENER · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 19 Jan 2024•Surrey

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
6

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Potentially very serious risks and side effects from excessive vitamin supplement intake
  2. Absence of appropriate dosage warnings and guidance for vitamin supplements
  3. Food labelling requirements failing to require warnings about risks and side effects on packaging
    Part of recurring concern: Inadequate product safety warnings about serious hazards

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. Department of Health and Social Care

    Meet with relevant food supplement trade associations to discuss the safety issues.

  2. Department of Health and Social Care

    Set up a sub-group to examine the vitamin supplement safety issues raised in the report.

  3. Department of Health and Social Care

    Notify relevant food supplement trade associations about the incident.

  4. Save On Supplements Ltd

    Review product operations and labelling following the inquest.

  5. Food Standards Agency

    Contact relevant local authorities to ascertain whether the product complies with food supplement requirements.

  6. Food Standards Agency

    Raise the report at the April cross-government Food Supplements Working Group and ensure consideration of its concerns.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Save On Supplements Ltd

    The evidence concerning Vitamin D toxicity was unclear because expert toxicological evidence was absent and calcium supplementation details were unavailable.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. Save On Supplements Ltd

    Overarching regulation of vitamin supplements is better addressed by the Food Standards Agency and Department of Health and Social Care.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  3. Save On Supplements Ltd

    Existing legal compliance, guidance adherence, consumer information and product labelling are considered sufficient to support safe Vitamin D supplement use.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  4. Food Standards Agency

    Amending key supplement legislation is assigned to Ministers in the respective nations.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  5. Food Standards Agency

    Policy advice on supplement composition and labelling in England is assigned to the Department of Health and Social Care.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Potentially very serious risks and side effects from excessive vitamin supplement intake

Wider context from the report

“(1) Vitamin supplements can have potentially very serious risks and side effects when taken in excess (2) Current food labelling requirements do not require these risks and side effects to be written on the packaging. (3) Absence of appropriate warnings and guidance about dosage ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Absence of appropriate dosage warnings and guidance for vitamin supplements

Wider context from the report

“(1) Vitamin supplements can have potentially very serious risks and side effects when taken in excess (2) Current food labelling requirements do not require these risks and side effects to be written on the packaging. (3) Absence of appropriate warnings and guidance about dosage ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Food labelling requirements failing to require warnings about risks and side effects on packaging

Wider context from the report

“(1) Vitamin supplements can have potentially very serious risks and side effects when taken in excess (2) Current food labelling requirements do not require these risks and side effects to be written on the packaging. (3) Absence of appropriate warnings and guidance about dosage ”

Is this part of a recurring concern?

Yes — Inadequate product safety warnings about serious hazards.

Open source report

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

Meet with relevant food supplement trade associations to discuss the safety issues.

Verbatim wording from the response

“In light of the concerns you raised, the issues in the PFD report were discussed at the Cross-Government Food Supplements Working Group meeting in April, which agreed to set up a sub-group to look at the issues raised in your report. We have also made relevant trade associations relating to food supplements aware of the incident and will meet with them in due course.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 22 February 2024

Open published response

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

Set up a sub-group to examine the vitamin supplement safety issues raised in the report.

Verbatim wording from the response

“In light of the concerns you raised, the issues in the PFD report were discussed at the Cross-Government Food Supplements Working Group meeting in April, which agreed to set up a sub-group to look at the issues raised in your report. We have also made relevant trade associations relating to food supplements aware of the incident and will meet with them in due course.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 22 February 2024

Open published response

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

Notify relevant food supplement trade associations about the incident.

Verbatim wording from the response

“In light of the concerns you raised, the issues in the PFD report were discussed at the Cross-Government Food Supplements Working Group meeting in April, which agreed to set up a sub-group to look at the issues raised in your report. We have also made relevant trade associations relating to food supplements aware of the incident and will meet with them in due course.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 22 February 2024

Open published response

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

Review product operations and labelling following the inquest.

Verbatim wording from the response

“The Company hopes that the above information provides reassurance to HM Coroner and Mr Mitchener’s family that it operates in a safe and compliant manner and has at its heart, the safety of its consumers. Indeed, following the Inquest, the Company reviewed its operations including the labelling of its products generally and remains confident that it continues to comply with the applicable law and guidance, and is industry standard.”

Source location

Response from Save on Supplements ltd on behalf of NaturPlus UK
Page 3 · response
Published 22 February 2024

Open published response

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

Contact relevant local authorities to ascertain whether the product complies with food supplement requirements.

Verbatim wording from the response

“The FSA will raise your report at the next cross-government Food Supplements Working Group, which will take place in April, and we will ensure full consideration will be given to the matters of concern you have highlighted. We intend to contact the relevant local authorities to ascertain whether the product is in compliance with food supplements requirements. We would be grateful if you could share any product details or packaging that you have, which will inform and aid our interactions with the relevant local authorities.”

Source location

Response from Food Standard Agency
Page 2 · response
Published 22 February 2024

Open published response

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

Raise the report at the April cross-government Food Supplements Working Group and ensure consideration of its concerns.

Verbatim wording from the response

“The FSA will raise your report at the next cross-government Food Supplements Working Group, which will take place in April, and we will ensure full consideration will be given to the matters of concern you have highlighted. We intend to contact the relevant local authorities to ascertain whether the product is in compliance with food supplements requirements. We would be grateful if you could share any product details or packaging that you have, which will inform and aid our interactions with the relevant local authorities.”

Source location

Response from Food Standard Agency
Page 2 · response
Published 22 February 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The evidence concerning Vitamin D toxicity was unclear because expert toxicological evidence was absent and calcium supplementation details were unavailable.

Verbatim wording from the response

“2.1 The Inquest did not have the benefit of any evidence from an expert Toxicologist, and/or any other witness with clinical expertise concerning Vitamin D toxicity. Indeed, the Pathologist who gave evidence at the inquest, fairly acknowledged that she was not an expert on this issue and when providing her evidence had regard to her internet-based research (the source of which was unclear), as opposed to her experience and professional expertise. In her evidence, the Pathologist fairly acknowledged there to be a range of opinion as to safe Vitamin D dosage.”

Source location

Response from Save on Supplements ltd on behalf of NaturPlus UK
Page 1 · response
Published 22 February 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Overarching regulation of vitamin supplements is better addressed by the Food Standards Agency and Department of Health and Social Care.

Verbatim wording from the response

“In your Report, you raised three Matters of Concern. We respectfully suggest that some of the Matters of Concern relating to the overarching regulation of vitamin supplements are better addressed by the Food Standards Agency and the Department of Health and Social Care. We note that you have also addressed the Report to these organisations who no doubt will respond directly.”

Source location

Response from Save on Supplements ltd on behalf of NaturPlus UK
Page 1 · response
Published 22 February 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Existing legal compliance, guidance adherence, consumer information and product labelling are considered sufficient to support safe Vitamin D supplement use.

Verbatim wording from the response

“The Company sells food supplement products, including those containing Vitamin D, via an online business platform. In the conduct of its business, the Company is compliant with the applicable law and available guidance.”

Source location

Response from Save on Supplements ltd on behalf of NaturPlus UK
Page 1 · response
Published 22 February 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Amending key supplement legislation is assigned to Ministers in the respective nations.

Verbatim wording from the response

“relation to England, we understand that DHSC is providing a response in respect to their policy. Powers to amend the key legislation in this area sits with Ministers in the respective nations. Co-ordination of policy takes place through a number of groups including the Food Supplements Working Group, which the FSA chairs.”

Source location

Response from Food Standard Agency
Page 2 · response
Published 22 February 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Policy advice on supplement composition and labelling in England is assigned to the Department of Health and Social Care.

Verbatim wording from the response

“The composition and labelling of supplements is devolved and policy advice to Ministers on it rests with a number of different bodies which includes the Department for Health and Social Care (DHSC) in England, Welsh Government, the FSA in Wales and Northern Ireland, and with Food Standards Scotland in Scotland. As your report is in”

Source location

Response from Food Standard Agency
Page 1 · response
Published 22 February 2024

Open published response
Back to top

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026