Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of dosage guidance for medications
The earlier warning
David Mitchener · 19 Jan 2024 · Jonathan Stevens, Surrey
“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”
judiciary.uk/…/david-mitchener-prevention-of-future-deaths-repo…
What was promised
Stated action 1 · response to David Mitchener (19 Jan 2024) · stated timescale: none stated
“Company will, of course, consider and take the necessary steps to implement the same with a view to ensuring its ongoing compliance with the”
judiciary.uk/…/2024-0083-Response-from-Save-on-Supplements-ltd.…
Stated action 2 · response to David Mitchener (19 Jan 2024) · stated timescale: none stated
“The Department has responsibility for the legislation governing food supplements in England, which is the Food Supplements (England) Regulations 2003, with parallel policy resting with the Welsh Government in Wales, Food Standards Scotland (FSS) in Scotland and the FSA in Northern Ireland. We work collaboratively with the FSA which has responsibility for food safety and Trading Standards and Environmental Health in local authorities who lead on enforcement of the regulations.”
judiciary.uk/…/2024-0083-Response-from-Department-of-Health-and…
What recurred
- 23 Apr 2025 · Christopher Brazil · Louisa Corcoran · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · David Mitchener · 19 Jan 2024
“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”
Later · Christopher Brazil · 23 Apr 2025
“(3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs (4) There is a lack of guidance regarding dosage”
What happened next
No web check of the stated actions has been published for this chain.