Bethany Victory Shipsey · Prevention of Future Deaths report

On 16th February 2017 I commenced an investigation into the death of Bethany Victory SHIPSEY aged 21

The investigation concluded at the end of the inquest on 14th February 2018.

The conclusion of the inquest was narrative (attached), the medical cause of death being Dinitrophenol poisoning.

Bethany Shipsey was a young woman with significant mental health difficulties who, on 15 February 2017, died as the result of suicide having deliberately ingested a quantity of tablets containing the drug Dinitrophenol which she had purchased over the Internet.

She did so intending to take her own life and was admitted into the Worcestershire Royal Hospital at approximately 5:30 PM on that day.

The clinicians having care of her recognised the extreme toxicity of the drug, the lack of antidote, the risk of rapid deterioration and the need for close monitoring of her condition with a view to providing supportive treatment.

Notwithstanding this clinicians failed to take sufficient or adequate steps to monitor her leaving them unprepared to deal with the rapid deterioration which ensued.

There were significant failings in the care given to her which amounted to a lost opportunity to provide supportive treatment which although probably would not have saved or prolonged her life may nevertheless have done so.

(1) : The inquest heard evidence from Prof Simon Thomas, the national clinical lead for Toxbase and acknowledged expert in dinitrophenol toxicity. His unchallenged evidence was that DNP is extremely toxic, with no known antidote and that it is becoming increasingly popular with young people as a “diet pill” and is freely available via the Internet.

There fatalities ████████ steps are taken to make it illegal to possess, sell or supply the drug. Given the tragic death of Ms Shipsey in the circumstances outlined above I invite the Secretary of State for Health to consider introducing legislation to make illegal the possession and supply of DNP.

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