Fatal self-poisoning with Cerbera manghas purchased through a U.K. homeware supply chain: A case report highlighting a novel consumer safety hazard

Background and aims Cerbera manghas is a highly cardiotoxic plant. Whilst fatal and non-fatal poisonings have been reported in South and Southeast Asia, cases in Western countries are rare. Here we describe a fatal self-poisoning involving C. manghas in England and examine the subsequent public health and regulatory response.Methods A case report identified through the National Programme on Substance Use Mortality was reviewed. Coroner records, post-mortem findings, botanical investigations and a Prevention of Future Deaths (PFD) report were examined. The Preventable Deaths Tracker was used to identify concerns raised by the coroner and actions taken by relevant agencies.Results A 50-year-old woman was found deceased at home. A letter detailing her actions and 10 fruit kernels missing their seeds were recovered at the scene. Severe decomposition precluded meaningful post-mortem examination and toxicological analysis. Investigation identified that the kernels had been advertised as a decorative homeware product and sold through a U.K. retail supply chain. Botanical assessment identified the material as C. manghas. The coroner concluded that death resulted from fatal C. manghas toxicity. A PFD report prompted regulatory action, including product withdrawal, retailer notifications, importer warnings and engagement with online marketplaces and trading standards authorities.Conclusions This case demonstrates an unusual route by which a highly toxic plant product entered the U.K. consumer market, and highlights the importance of integrating coronial, botanical and surveillance data when toxicological confirmation is unavailable. It also illustrates how individual death investigations can identify previously unrecognised public health hazards and trigger preventive regulatory action.