Recurring concern

Inadequate controls on the sale and online access to highly toxic substances

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First reported 27 Nov 2013•Latest report 9 Jul 2025

Definition

What this concern includes

Includes failures of controls specifically intended to regulate, restrict, monitor or provide safeguards around the retail or online sale and purchase of highly toxic or potentially fatal substances, including inadequate regulated-poison controls, unrestricted quantities and absent internet-sale protections.

Not included

Excludes ordinary medication, prescription-only medicine and controlled-drug supply concerns where the shared issue is medication regulation rather than access to highly toxic substances.
Excludes hazards involving toxic substances where no deficiency in sale, purchase, access or regulatory control is identified.
Excludes product-safety, labelling or consumer-information failures that do not concern controlling access to highly toxic or potentially fatal substances.
Excludes generic regulatory gaps unrelated to the sale or online access of toxic substances.

Reports: 16
Individual concerns: 22
Date range: 2013–2025
Stated actions: 36

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care10

Home Office7

Advisory Council on the Misuse of Drugs2

Ebay (UK) Limited2

Chartered Trading Standards Institute1

Department for Business, Innovation & Skills1

Department for Science, Innovation and Technology1

Metalchem Limited1

Oldham Borough Council1

Public Health England1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

9 Jul2025
Surrey
Concerns raised2
1. Lack of domestic restrictions on purchase of reportable substances
2. Sale of reportable substances at lethal purity and quantities
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Assess the feasibility of additional regulatory and non-regulatory controls for the substance.
  Stated by Home OfficeStated in progress
2. Action
  Engage online platforms and retailers to promote responsible sales and voluntary removal of pure-form sales to the public.
  Stated by Home OfficeStated in progress
Respondent positions 1
1. Position
  Responsibility for concerns about access to large amounts of sodium nitrite sits with another organisation.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Andrew Nathan Paul Kenward · 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

Andrew Nathan Paul Kenward was found deceased in his car on 24 October 2022 after an overdose of a poisonous substance. He had previously expressed an intention to end his life, and the inquest recorded a conclusion of suicide. The concerns included the availability, purity and quantity of certain reportable substances, limited monitoring and restrictions, and the absence of apparent consideration of measures to reduce the risk to life.

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.
PFD Monitor interpretation
Lack of domestic restrictions on purchase of reportable substances
Wider context from the report
“A lethal dose of ████████ can be as small as 1g. Mr Kenward was able to procure a total of 1kg of ████████ at 99.999% purity. Coroners including myself have previously raised in Prevention of Future Death reports that there is no central monitoring system which is able to record incidents of sodium nitrite poisoning, although the use of sodium nitrite for self-harm is increasing. ████████ and ████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. Whilst the source of this particular ████████ is not currently known, there are no restrictions on the import of ████████ or ████████ from abroad. Whilst these substances have legitimate uses, including meat preservation, there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose. - ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions; - ████████ can be purchased from abroad and imported to Great Britain with no restrictions; - ████████ is sold at levels of purity (99%) and in quantities which represent significant risk to life (up to 1000 fatal doses for 1kg sale), whether by self-harm or terrorist use; - The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use, for example in meat preservation; - It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this. Consideration should be given as to whether any steps can be taken to address the above concerns. ”
Source location
Andrew Nathan Paul Kenward · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Sale of reportable substances at lethal purity and quantities
Wider context from the report
“A lethal dose of ████████ can be as small as 1g. Mr Kenward was able to procure a total of 1kg of ████████ at 99.999% purity. Coroners including myself have previously raised in Prevention of Future Death reports that there is no central monitoring system which is able to record incidents of sodium nitrite poisoning, although the use of sodium nitrite for self-harm is increasing. ████████ and ████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. Whilst the source of this particular ████████ is not currently known, there are no restrictions on the import of ████████ or ████████ from abroad. Whilst these substances have legitimate uses, including meat preservation, there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose. - ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions; - ████████ can be purchased from abroad and imported to Great Britain with no restrictions; - ████████ is sold at levels of purity (99%) and in quantities which represent significant risk to life (up to 1000 fatal doses for 1kg sale), whether by self-harm or terrorist use; - The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use, for example in meat preservation; - It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this. Consideration should be given as to whether any steps can be taken to address the above concerns. ”
Source location
Andrew Nathan Paul Kenward · Prevention of Future Deaths report
Page 2 · concerns
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
Assess the feasibility of additional regulatory and non-regulatory controls for the substance.

Verbatim wording from the response
“includes targeted action on emerging methods of suicide. In recent months, my officials have been working with the Department of Health and Social Care (DHSC) and other departments to assess the feasibility of additional regulatory and non-regulatory levers for the substance in question. A cross-government workshop took place in June to explore these options. Further meetings will shortly be held between senior officials to agree recommendations for a coordinated government response.”

Source location
2025-0346 Response from Home Office
Page 2 · response
Published 16 July 2025
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
Engage online platforms and retailers to promote responsible sales and voluntary removal of pure-form sales to the public.

Verbatim wording from the response
“In the meantime, the Home Office continues to engage with industry to promote responsible sales practices. My officials have engaged with selected online platforms and retailers individually to encourage them to voluntarily remove the sale of these substances to members of the public in their pure form, and be vigilant for the possibility of purchase for self-harm or suicide. For all substances within scope of the Poisons Act, the Homeland Security Group works to improve retailer awareness of their legal obligation to report suspicious activity and to inform retailers sales practices. For example, we encourage suppliers to use declaration of use forms for sales of potentially harmful substances. This work will continue to ensure suppliers are meeting their obligations under the Poisons Act.”

Source location
2025-0346 Response from Home Office
Page 2 · response
Published 16 July 2025
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
Responsibility for concerns about access to large amounts of sodium nitrite sits with another organisation.

Verbatim wording from the response
“The report raises concerns over the fact that Mr Kenward was able to buy large amounts of sodium nitrite. Officials within the Department of Health and Social Care have considered these concerns and concluded that the responsibility for these concerns sits within another organisation. I understand that this report was also made to the Home Office, and I hope that their response will be helpful.”

Source location
Response from Department for Health and Social Care
Page 1 · response
Published 16 July 2025
Open published response
23 May2025
Manchester West
Concerns raised2
1. Lack of specific seller guidance and training for one-off online marketplace purchases for self-harm
2. Failure to correctly evaluate small-quantity purchase patterns
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Matthew Joseph O’Reilly · 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

Matthew Joseph O’Reilly was found collapsed and unresponsive in his locked student accommodation room on 25 September 2020 and was pronounced dead after attempted resuscitation. Postmortem testing found recently ingested, significant and fatally toxic levels of a substance, and the inquest concluded that he died following deliberate self-ingestion, although his intentions remained unclear. The report raised concerns about gaps in guidance and oversight for the sale of a reportable poison, particularly through online marketplaces, and about public access to websites promoting poison-based suicide methods.

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.
PFD Monitor interpretation
Lack of specific seller guidance and training for one-off online marketplace purchases for self-harm
Wider context from the report
“1. ████████ is a reportable poison as well as a reportable explosives precursor within the terms, meaning and effect of Part 4 of Schedule 1A of the Poisons Act 1972 with the consequence that: a. The Poisons Act 1972 sets out the legal obligations in relation to the sale, purchase, and use of these chemicals for suppliers, professional users and members of the public. b. The published Guidance (commenced in 2014 and updated in August 2024) does not give specific guidance or suggested training for sellers, particularly ████████ acquired by members of the public, particularly over ‘online marketplaces’ in circumstances of the purchase on a ‘one off’ basis for the means of self-harm. c. Whilst there is a legal duty on persons selling this substance to report “suspicious” transactions within 24 hours to the Home Office, the purchase of small quantities is being presumed to be connected to the many legitimate uses of the substance (such as food preservation, fertilizer etc) rather than in fact, being evaluated as a member of the public seeking purchase of modest quantities used as their chosen means by which to end life. d. The current Home Office guidance and supporting video, leaflet and posters do not reference ████████ as a specific example of concern and focuses on the phenomenon of ‘malicious’ misuse and not deliberate misuse in the sense of suicide/self-harm. ”
Source location
Matthew Joseph O’Reilly · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to correctly evaluate small-quantity purchase patterns
Wider context from the report
“2. The police investigation into one UK based source of supply revealed in 247 cases separate supplies of 500 grams of less of ████████ to customers in the UK and Europe, police established that 85 of these individuals who were traceable had either died as the consequence of self-ingestion of the substance, or had purchased it with a view to having the means to use this method to end their life in circumstances where: a. the vendors of ████████ were not aware of this potential misuse of the substance. b. the small quantities being purchased had been incorrectly evaluated to be an increase in individuals pursuing recreational home-curing/food preservations as a hobby, being an artefact of ‘lockdown’ living following the COVID national pandemic emergency. c. Vendors were unaware that their website/details were being distributed as part of internet information platforms designed to aid, abet, assist or promote suicide methods. d. From the specific example of 247 supplies in a 12 month period, police established that 45 purchasers were confirmed as deceased (these deaths were in relation to supplies to UK customers and purchasers from abroad) and only 15 purchases were confirmed to have taken place for legitimate purposes (meat curing etc.). ”
Source location
Matthew Joseph O’Reilly · Prevention of Future Deaths report
Page 2 · concerns
Open source report
14 Nov2024
Surrey
Concerns raised2
1. Unrestricted domestic sale of the substances
2. Lack of consideration of controls on the quantities and purity in which the substances are sold
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 8
1. Action
  Strengthen controls on reportable poisons, including suspicious-transaction reporting, online-marketplace obligations, and supplier personnel awareness requirements.
  Stated by Home OfficeStated completed
2. Action
  Improve retailer awareness of legal reporting duties and engage online platforms to encourage removal of pure-form sales and use of declarations of intended use.
  Stated by Home OfficeStated in progress
3. Action
  Continue work to ensure suppliers meet their obligations under the Poisons Act.
  Stated by Home OfficeStated in progress
1. Action
  Operate the Concerning Methods Working Group to develop and deliver targeted actions reducing public access to emerging suicide methods.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Work with businesses, online suppliers and manufacturers to reduce non-legitimate purchasing and raise safeguarding awareness.
  Stated by Department of Health and Social CareStated completed
3. Action
  Work with online platforms to remove the substance from sale to individuals in its pure form.
  Stated by Department of Health and Social CareStated completed
4. Action
  Continue operational work with organisations to reduce access to concerning methods.
  Stated by Department of Health and Social CareStated in progress
5. Action
  Work with the Department of Health and Social Care and relevant stakeholders to assess the benefits and proportionality of further regulation addressing overseas sales, purity, and quantities.
  Stated by Home OfficeStated in progress
AI-generated summary

Hannah Mary AITKEN · 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

Hannah Mary Aitken died at her supported accommodation on 14 September 2023 after taking an overdose of a poisonous substance obtained with the intention of ending her life. The report raises concerns about the unrestricted domestic and international availability of the substance, the quantities and purity in which it is sold, and the lack of central monitoring or clear responsibility for regulating its use in relation to self-harm.

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.
PFD Monitor interpretation
Unrestricted domestic sale of the substances
Wider context from the report
“The Court heard anecdotal evidence from three Emergency Medical Consultants and others witnesses that in their direct experience, the use of ████████ for self-harm is increasing. However, none were aware of a central monitoring system which is able to record incidents of ████████ poisoning. ████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. There are no restrictions on the import of ████████ from abroad. Since 2020, the Home Office has received at least five Prevention of Future Death Reports relating to ████████ The Home Secretary has recently provided reassurance in response to the Regulation 28 report relating to the death of Dr Jonathan Shaw that “the Home Office is actively exploring legislative and policy options, including working with or alongside officials of other Government Departments as appropriate, for the control of ████████ (and other similar substances)”. The Home Office has clarified in evidence during this inquest that the policy objective of the Poisons Act 1972 is to control access to explosives precursors and poisons and to detect terrorist use of these substances to illicitly manufacture explosives or to cause harm to third parties. Prevention of suicide/self-harm is not a policy objective of the Home Office under this Act, and this falls under the remit of the Department for Health and Social Care. No evidence was provided that there is active consideration of controlling access to these substances to the general public, whether under the remit of the Home Office or any other Government department. Whilst these substances have legitimate uses, including ████████ ████████ there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose. - ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions; - ████████ can be purchased from abroad and imported to Great Britain with no restrictions; ████████ ████████ - The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use, for example in ████████ - It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this. Consideration should be given to whether any steps can be taken to address the above concerns. ”
Source location
Hannah Mary AITKEN · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of consideration of controls on the quantities and purity in which the substances are sold
Wider context from the report
“The Court heard anecdotal evidence from three Emergency Medical Consultants and others witnesses that in their direct experience, the use of ████████ for self-harm is increasing. However, none were aware of a central monitoring system which is able to record incidents of ████████ poisoning. ████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. There are no restrictions on the import of ████████ from abroad. Since 2020, the Home Office has received at least five Prevention of Future Death Reports relating to ████████ The Home Secretary has recently provided reassurance in response to the Regulation 28 report relating to the death of Dr Jonathan Shaw that “the Home Office is actively exploring legislative and policy options, including working with or alongside officials of other Government Departments as appropriate, for the control of ████████ (and other similar substances)”. The Home Office has clarified in evidence during this inquest that the policy objective of the Poisons Act 1972 is to control access to explosives precursors and poisons and to detect terrorist use of these substances to illicitly manufacture explosives or to cause harm to third parties. Prevention of suicide/self-harm is not a policy objective of the Home Office under this Act, and this falls under the remit of the Department for Health and Social Care. No evidence was provided that there is active consideration of controlling access to these substances to the general public, whether under the remit of the Home Office or any other Government department. Whilst these substances have legitimate uses, including ████████ ████████ there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose. - ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions; - ████████ can be purchased from abroad and imported to Great Britain with no restrictions; ████████ ████████ - The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use, for example in ████████ - It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this. Consideration should be given to whether any steps can be taken to address the above concerns. ”
Source location
Hannah Mary AITKEN · Prevention of Future Deaths report
Page 3 · concerns
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
Strengthen controls on reportable poisons, including suspicious-transaction reporting, online-marketplace obligations, and supplier personnel awareness requirements.

Verbatim wording from the response
“The substance described in your report is a “reportable” poison listed in Part 4 of Schedule 1A of the Poisons Act. For the avoidance of doubt, this means that whilst it can be bought by members of the public, suspicious transactions need to be reported by retailers if there are questionable grounds for suspecting it is intended for any illicit use. The Poisons Act was amended in October 2023 to strengthen controls, and enhance our suspicious activity reporting requirements, including new obligations for online marketplaces. As well as the requirement to report suspicious transactions, economic operators supplying any reportable substances must now demonstrate that their personnel are aware about which of their products contain listed substances, and are instructed on their obligations.”

Source location
Response from the Home Office
Page 2 · response
Published 14 November 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
Improve retailer awareness of legal reporting duties and engage online platforms to encourage removal of pure-form sales and use of declarations of intended use.

Verbatim wording from the response
“As your report captures, the Home Office is aware of the issues relating to this substance. My officials have been undertaking work across Government to both reduce access to this substance, and raise awareness to suppliers of the dangers of this substance. To this end, the Homeland Security Group (HSG) have been working to improve retailer awareness of their legal obligation to report suspicious activity for regulated and reportable substances.”

Source location
Response from the Home Office
Page 2 · response
Published 14 November 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
Continue work to ensure suppliers meet their obligations under the Poisons Act.

Verbatim wording from the response
“Specifically, HSG have engaged with online platforms to encourage them to voluntarily remove the sale to individuals in its pure form. Government expertise in relation to substances of concern is also shared to inform retailer sales practices. This includes encouraging suppliers to use declaration of use forms for sales of such substances. This work will continue to ensure suppliers are meeting their requirements under the Poisons Act. Furthermore, if during the processing of suspicious activity reports a safeguarding concern is identified by Counter Terrorism Policing, consideration will be given to disseminating this intelligence to police forces to consider a welfare check.”

Source location
Response from the Home Office
Page 2 · response
Published 14 November 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
Operate the Concerning Methods Working Group to develop and deliver targeted actions reducing public access to emerging suicide methods.

Verbatim wording from the response
“On methods of suicide specifically, Government departments have taken steps to reduce access to, and awareness of, this substance. DHSC leads a Concerning Methods Working Group to raise awareness of and tackle access to substances such as this one. The working group involves representatives from the voluntary, community and social enterprise sector, police, academics and the NHS, as well as Government departments including Department of Science, Innovation and Technology and the Home Office. The group develops and delivers rapid targeted actions to collectively reduce public access to emerging methods, including this one. Over 30 of the actions identified and implemented by the group have been to tackle this substance specifically.”

Source location
Response from DHSC
Page 1 · response
Published 14 November 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
Work with businesses, online suppliers and manufacturers to reduce non-legitimate purchasing and raise safeguarding awareness.

Verbatim wording from the response
“The group has worked with businesses, including online suppliers and manufacturers of the substance, to reduce people’s ability to purchase it for non-legitimate purposes including suicide, and to raise awareness around safeguarding concerns with businesses where required. Government departments have also previously worked with manufacturers to reduce the lethality of the substance if ingested. This included work with online platforms to remove it from sale to individuals in its pure form. The group continues to work operationally with a range of organisations, and we are actively considering opportunities to work with the Border Force, using existing legal provisions, to help detect packages at the border which may be linked to vulnerable individuals and intended for suicide. The group’s actions are kept under review.”

Source location
Response from DHSC
Page 2 · response
Published 14 November 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
Work with online platforms to remove the substance from sale to individuals in its pure form.

Verbatim wording from the response
“The group has worked with businesses, including online suppliers and manufacturers of the substance, to reduce people’s ability to purchase it for non-legitimate purposes including suicide, and to raise awareness around safeguarding concerns with businesses where required. Government departments have also previously worked with manufacturers to reduce the lethality of the substance if ingested. This included work with online platforms to remove it from sale to individuals in its pure form. The group continues to work operationally with a range of organisations, and we are actively considering opportunities to work with the Border Force, using existing legal provisions, to help detect packages at the border which may be linked to vulnerable individuals and intended for suicide. The group’s actions are kept under review.”

Source location
Response from DHSC
Page 2 · response
Published 14 November 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
Continue operational work with organisations to reduce access to concerning methods.

Verbatim wording from the response
“The group has worked with businesses, including online suppliers and manufacturers of the substance, to reduce people’s ability to purchase it for non-legitimate purposes including suicide, and to raise awareness around safeguarding concerns with businesses where required. Government departments have also previously worked with manufacturers to reduce the lethality of the substance if ingested. This included work with online platforms to remove it from sale to individuals in its pure form. The group continues to work operationally with a range of organisations, and we are actively considering opportunities to work with the Border Force, using existing legal provisions, to help detect packages at the border which may be linked to vulnerable individuals and intended for suicide. The group’s actions are kept under review.”

Source location
Response from DHSC
Page 2 · response
Published 14 November 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
Work with the Department of Health and Social Care and relevant stakeholders to assess the benefits and proportionality of further regulation addressing overseas sales, purity, and quantities.

Verbatim wording from the response
“On the issue of further regulation, an aspect of the concern you have raised relates to individuals based in Great Britain, purchasing this substance from overseas retailers. As the Poisons Act only applies to Great Britain (i.e. England, Scotland, and Wales), there is no obligation for retailers based outside the specified jurisdiction to report transactions which they believe to be suspicious. The Department is seeking to address this, as well as”

Source location
Response from the Home Office
Page 2 · response
Published 14 November 2024
Open published response
30 Jul2024
Nottinghamshire
Concerns raised2
1. Continued ease of public availability of the substance
2. Lack of business awareness that the substance is being obtained for suicide
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Coordinate cross-sector work through an emerging methods working group to reduce public access to and awareness of suicide methods.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Work with online suppliers and manufacturers to remove the substance from sale to individuals in its pure form.
  Stated by Department of Health and Social CareStated completed
3. Action
  Continue operational collaboration with Border Force, police and other partners to reduce access to the substance for suicide purposes.
  Stated by Department of Health and Social CareStated in progress
AI-generated summary

Bethany Paige Langton · 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

Bethany Paige Langton, aged 22, was discovered deceased in her bedroom on 18 February 2023 after deliberately ingesting a substance sourced online with the intention of causing her death. The principal concerns were the substance’s easy online availability, limited awareness among businesses that it could be obtained for suicide, and the continued availability of online guidance about sourcing and using it for that purpose.

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.
PFD Monitor interpretation
Continued ease of public availability of the substance
Wider context from the report
“1. The continued ease of availability of ████████ to members of the public. The substance is lethal when ingested, even in relatively small quantities. It’s use in suicide is increasing. The substance is readily available to purchase online without the need for any explanation of the purchaser’s intended use for the substance, or an end user certificate/licence to track where it is being distributed. ”
Source location
Bethany Paige Langton · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of business awareness that the substance is being obtained for suicide
Wider context from the report
“2. Lack of awareness amongst businesses that the substance is being obtained for this purpose. The company who supplied Beth with the ████████ used in her death, had no idea that the substance might be sourced by individuals for this purpose. Had they have been aware of the risk, they would likely have improved systems for investigating the intended use, or would have stopped offering the item for sale to individuals, as they have now done so. ”
Source location
Bethany Paige Langton · Prevention of Future Deaths report
Page 1 · concerns
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
Coordinate cross-sector work through an emerging methods working group to reduce public access to and awareness of suicide methods.

Verbatim wording from the response
“The Government has taken steps to reduce access to and awareness of this substance and therefore reduce the risks of further deaths by suicide. The Department of Health and Social Care leads an emerging methods working group to prevent awareness and access to substances such as this one. The working group involves representatives from the voluntary, community and social enterprises sector, police, academics, and the NHS, as well as government departments including the Home Office and the Department for Science, Innovation and Technology. The group ensures rapid targeted actions to collectively reduce public access to emerging methods, including this particular substance. This includes reducing the sale and importation of methods where appropriate as well as reducing references to, and limiting awareness of, them.”

Source location
Response from DHSC
Page 1 · response
Published 14 October 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
Work with online suppliers and manufacturers to remove the substance from sale to individuals in its pure form.

Verbatim wording from the response
“The group has worked with business, including online suppliers and manufacturers of the substance, to significantly reduce access. We have also worked with major online suppliers to remove it from sale to individuals in its pure form. We continue to work operationally with our broader partners, including Border Force and the police on interventions to reduce access to this specific substance for the purpose of suicide. These actions are kept under operational review.”

Source location
Response from DHSC
Page 2 · response
Published 14 October 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
Continue operational collaboration with Border Force, police and other partners to reduce access to the substance for suicide purposes.

Verbatim wording from the response
“The group has worked with business, including online suppliers and manufacturers of the substance, to significantly reduce access. We have also worked with major online suppliers to remove it from sale to individuals in its pure form. We continue to work operationally with our broader partners, including Border Force and the police on interventions to reduce access to this specific substance for the purpose of suicide. These actions are kept under operational review.”

Source location
Response from DHSC
Page 2 · response
Published 14 October 2024
Open published response
14 Oct2022
Surrey
Concerns raised1
1. Availability of lethal quantities for internet purchase and UK delivery
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Work closely with the Home Office on safeguards concerning public access to the chemical and sellers’ suspicious-transaction reporting obligations.
  Stated by Department of Health and Social CareStated in progress
Respondent positions 1
1. Position
  Regulation of the substance purchased online as a non-licensed or counterfeit medicine falls outside the MHRA’s remit.
  Stated by Department of Health and Social CareOutside remit
AI-generated summary

Neha Susan RAJU · 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

Neha Susan Raju was found deceased by emergency services in her bedroom in Guildford, Surrey, on 10 April 2022 after her family raised concerns that she was not responding to calls or messages. The report identified concerns that a substance was freely available to purchase online in lethal quantities for delivery within the UK, with no protection for vulnerable people before such purchases were made.

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.
PFD Monitor interpretation
Availability of lethal quantities for internet purchase and UK delivery
Wider context from the report
“- ████████ is freely available to be purchased from the internet in lethal quantities for delivery within the UK ”
Source location
Neha Susan RAJU · Prevention of Future Deaths report
Page 2 · concerns
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
Work closely with the Home Office on safeguards concerning public access to the chemical and sellers’ suspicious-transaction reporting obligations.

Verbatim wording from the response
“With regard to the sale of the chemical used in this case, Department officials work closely with the Home Office on this matter, and I understand from them that this chemical is available to the public for legitimate uses. It is, however, included in The Poisons Act 1972 as a reportable substance, meaning that while it is generally available without the need for a licence, sellers (including online sellers) are obligated to make suspicious transaction reports, whether they process the transaction or not, where they have grounds to believe that the sale is for an illicit use.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 14 October 2022
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
Regulation of the substance purchased online as a non-licensed or counterfeit medicine falls outside the MHRA’s remit.

Verbatim wording from the response
“In preparing this response, Departmental officials have made enquiries with the Medicines and Healthcare products Regulatory Agency (MHRA). The MHRA have advised that they are responsible for regulating the substance used in this case, when it is used as a licensed medicine, in the form of a solution for injection. It is a prescription only medicine and has an indication for cyanide poisoning. This substance in other forms is used in other sectors, such as food manufacturing. However, when the purchase of this substance over the internet is not a licensed medicine, or counterfeit medicine, it is not within the remit of the MHRA.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 14 October 2022
Open published response
13 Apr2021
Surrey
Concerns raised1
1. Lack of restriction on the quantity of butane gas that can be purchased
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

NATASHA JENNIFER IRENE CRABB · 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

Natasha Jennifer Irene Crabb died at Princess Gardens, Woking, on 29 June 2018 after continuing to inhale butane gas following her self-discharge from hospital. The substantive concerns were that inhaling butane was lawful, there were no legal powers to prevent a person with capacity from inhaling it or to remove it from them, and there was no restriction on the amount of butane that could be purchased.

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.
PFD Monitor interpretation
Lack of restriction on the quantity of butane gas that can be purchased
Wider context from the report
“2. There is no restriction on the amount of butane gas that can be purchased making it easy for a person addicted to inhaling butane gas to obtain large amounts of the gas at one time. ”
Source location
NATASHA JENNIFER IRENE CRABB · Prevention of Future Deaths report
Page 2 · concerns
Open source report
4 Jan2021
Surrey
Concerns raised1
1. Failure to restrict purchase of lethal quantities from UK websites
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Implement the Suicide Prevention Strategy and Cross-Government Suicide Prevention Workplan, including measures to reduce access to suicide methods.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Work with government departments to explore further measures addressing this chemical and emerging suicide methods.
  Stated by Department of Health and Social CareStated in progress
3. Action
  Invite Home Office officials to brief NHS, public health and suicide prevention partners on chemical-sale safeguards and support for people at risk.
  Stated by Department of Health and Social CareStated completed
Respondent positions 1
1. Position
  Concerns about selling reportable substances fall within the Home Office’s policy remit.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Linda Joan Gillchrest · 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

Linda Joan Gillchrest was found dead at home on 19 July 2020 after not being seen for two days. The inquest heard that she had purchased online a publication containing detailed instructions for self-administering a fatal dose and had bought a quantity of a substance in excess of the recommended fatal dose without restriction. The principal concerns were the unrestricted online availability of such publications and lethal quantities of substances, and the lack of protection for vulnerable people before such purchases.

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.
PFD Monitor interpretation
Failure to restrict purchase of lethal quantities from UK websites
Wider context from the report
“During the course of the inquest, evidence was heard that in May 2019 Mrs Gillchrest bought an e-book online from the USA, titled ████████ from a website of the same name. The book gave very clear and precise instructions as to how to self-administer a fatal dose of ████████, including the amount required and a timeline to death. In that month, for less than £5:00, pounds, Mrs Gillchrest purchased, on the auction site ‘www.ebay.co.uk’, a quantity of ████████ that was in excess of that recommended in ████████ as being required for a fatal dose. Both purchases were made without any restriction being imposed by the sellers. • A publication such as ████████, that contains detailed instructions as to how to end a human life, is available to be purchased online without restriction. • ████████ is available to be purchased in lethal quantities from a UK website for less than £5:00, again without restriction. • No protection is afforded to vulnerable people prior to them making such purchases. Consideration should be given to whether any steps can be taken to address the above concerns. ”
Source location
Linda Joan Gillchrest · Prevention of Future Deaths report
Page 2 · concerns
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
Implement the Suicide Prevention Strategy and Cross-Government Suicide Prevention Workplan, including measures to reduce access to suicide methods.

Verbatim wording from the response
“We continue to take action to reduce suicide rates through the Suicide Prevention Strategy for England¹ and the first Cross-Government Suicide Prevention Workplan², which sets out an ambitious programme across national and local government and the NHS. The Workplan includes actions to reduce access to the means of suicide, including through harmful online content.”

Source location
2021-0002-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
Page 1 · response
Published 14 January 2021
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
Work with government departments to explore further measures addressing this chemical and emerging suicide methods.

Verbatim wording from the response
“The concerns that Mrs Gillchrest’s death raises sit within the policy remits of a range of Government departments, including the Department for Digital, Culture, Media and Sports (DCMS) for its work on online harms; and the Home Office (HO) for its work on the sale of reportable substances³. Officials have shared your concerns with those Departments and are working with officials from those and other Government departments to explore what further steps we can take to prevent further tragedies, both for this chemical, and any other emerging methods.”

Source location
2021-0002-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
Page 2 · response
Published 14 January 2021
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
Invite Home Office officials to brief NHS, public health and suicide prevention partners on chemical-sale safeguards and support for people at risk.

Verbatim wording from the response
“In addition to the cross-Government group set up to put in place steps to tackle emerging methods of suicide, officials at the Department of Health and Social Care have also invited HO officials to brief partners in NHSEI, PHE and suicide prevention stakeholders on what HO can do to ensure that sellers of these chemicals are aware of their potential use in suicide, and on what can be done to get specialist support to those who might be at risk.”

Source location
2021-0002-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
Page 3 · response
Published 14 January 2021
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
Concerns about selling reportable substances fall within the Home Office’s policy remit.

Verbatim wording from the response
“The concerns that Mrs Gillchrest’s death raises sit within the policy remits of a range of Government departments, including the Department for Digital, Culture, Media and Sports (DCMS) for its work on online harms; and the Home Office (HO) for its work on the sale of reportable substances³. Officials have shared your concerns with those Departments and are working with officials from those and other Government departments to explore what further steps we can take to prevent further tragedies, both for this chemical, and any other emerging methods.”

Source location
2021-0002-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
Page 2 · response
Published 14 January 2021
Open published response
26 Nov2020
Cumbria
Concerns raised1
1. Lack of safeguards for internet purchase of toxic substances
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Operate a cross-Government group to develop measures addressing emerging suicide methods.
  Stated by Department of Health and Social CareStated completed
2. Action
  Work with other Government departments to explore further steps preventing deaths involving this chemical and emerging suicide methods.
  Stated by Department of Health and Social CareStated in progress
3. Action
  Invite Home Office officials to brief NHS, public health and suicide prevention partners on chemical-sale safeguards and support for people at risk.
  Stated by Department of Health and Social CareStated completed
Respondent positions 1
1. Position
  Controls on the sale of reportable substances fall within the Home Office’s policy remit.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Lee Elliott · 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

Lee Elliott had experienced mental health difficulties and was found deceased in his bedroom on 6 February 2020. The inquest recorded that he had purchased a chemical from an internet supplier and ingested it, causing his death. The principal concerns were the online promotion of the substance as a suicide method and its easy, inexpensive purchase without safeguards.

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.
PFD Monitor interpretation
Lack of safeguards for internet purchase of toxic substances
Wider context from the report
“(2) ████████ [and other toxic substances] are easily and cheaply obtainable in small amounts by internet purchase with no safeguards. ”
Source location
Lee Elliott · Prevention of Future Deaths report
Page 2 · concerns
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
Operate a cross-Government group to develop measures addressing emerging suicide methods.

Verbatim wording from the response
“We continue to take action to reduce suicide rates through the Suicide Prevention Strategy for England¹ and the first Cross-Government Suicide Prevention Workplan², which sets out an ambitious programme across national and local government and the NHS. The Workplan includes actions to reduce access to the means of suicide, including through harmful online content.”

Source location
2020-0265-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
Page 1 · response
Published 4 January 2021
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
Work with other Government departments to explore further steps preventing deaths involving this chemical and emerging suicide methods.

Verbatim wording from the response
“The concerns that Mr Elliott’s death raises sit within the policy remits of a range of Government departments, including the Department for Digital, Culture, Media and Sports (DCMS) for its work on online harms; and the Home Office (HO) for its work on the sale of reportable substances³. Officials have shared your concerns with those Departments and are working with officials from those and other Government departments to explore what further steps we can take to prevent further tragedies, both for this chemical, and any other emerging methods.”

Source location
2020-0265-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
Page 2 · response
Published 4 January 2021
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
Invite Home Office officials to brief NHS, public health and suicide prevention partners on chemical-sale safeguards and support for people at risk.

Verbatim wording from the response
“In addition to the cross-Government group set up to put in place steps to tackle emerging methods of suicide, officials at the Department of Health and Social Care have also invited HO officials to brief partners in NHSEI, PHE and suicide prevention stakeholders on what HO can do to ensure that sellers of these chemicals are aware of their potential use in suicide, and what can be done to get specialist support to those who might be at risk.”

Source location
2020-0265-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
Page 3 · response
Published 4 January 2021
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
Controls on the sale of reportable substances fall within the Home Office’s policy remit.

Verbatim wording from the response
“The concerns that Mr Elliott’s death raises sit within the policy remits of a range of Government departments, including the Department for Digital, Culture, Media and Sports (DCMS) for its work on online harms; and the Home Office (HO) for its work on the sale of reportable substances³. Officials have shared your concerns with those Departments and are working with officials from those and other Government departments to explore what further steps we can take to prevent further tragedies, both for this chemical, and any other emerging methods.”

Source location
2020-0265-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
Page 2 · response
Published 4 January 2021
Open published response
20 Nov2020
County Durham and Darlington
Concerns raised1
1. Unrestricted availability of a lethal substance as a meat preservative
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 11
1. Action
  Continue implementing suicide-prevention strategy and cross-government workplan measures to reduce access to suicide methods and harmful online content.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Investigate available data on suicides using this method and identify steps to prevent further deaths from this and emerging methods.
  Stated by Department of Health and Social CareStated in progress
3. Action
  Work with other government departments to explore further measures addressing this chemical and emerging suicide methods.
  Stated by Department of Health and Social CareStated in progress
1. Action
  Invite Home Office officials to brief NHS, public health and suicide-prevention partners on chemical-seller safeguards and specialist support for people at risk.
  Stated by Department of Health and Social CareStated completed
2. Action
  Withdraw Sodium Nitrite listings from Metalchem’s eBay sales.
  Stated by Metalchem LimitedStated completed
3. Action
  Contact other online sellers to request removal of Sodium Nitrite listings where the purchase purpose cannot reasonably be ascertained.
  Stated by Metalchem LimitedStated completed
4. Action
  Coordinate removal of persistent Sodium Nitrite sellers’ listings on eBay and Etsy.
  Stated by Metalchem LimitedStated completed
5. Action
  Report the remaining Sodium Nitrite listing shipping to the United Kingdom for removal or restriction.
  Stated by Metalchem LimitedStated planned
6. Action
  Prohibit the global sale of sodium nitrite as a chemical.
  Stated by Ebay (UK) LimitedStated completed
7. Action
  Improve and continuously update filters and blocking algorithms to detect and prevent sodium nitrite listings.
  Stated by Ebay (UK) LimitedStated in progress
8. Action
  Continue working with relevant authorities to monitor developments and rigorously enforce the sodium nitrite prohibition.
  Stated by Ebay (UK) LimitedStated in progress
Respondent positions 2
1. Position
  Online-harm concerns are assigned to DCMS, while concerns about sale of reportable substances are assigned to the Home Office.
  Stated by Department of Health and Social CareRedirects responsibility
1. Position
  Curing salts may continue to be sold because their low sodium nitrite content and emetic effects make harmful ingestion less likely.
  Stated by Ebay (UK) LimitedDisputes the concern
AI-generated summary

Jason THOMPSON · 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

Jason THOMPSON, a 49-year-old man, collapsed at home after taking a quantity of a substance and died shortly afterwards in Darlington Memorial Hospital on 8 February 2020. The concerns included the ready availability of a lethal substance, including through a popular online platform, and material allegedly describing its use to commit suicide and potentially promoting that method.

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.
PFD Monitor interpretation
Unrestricted availability of a lethal substance as a meat preservative
Wider context from the report
“‘████████ is used to preserve and cure meat, to which it imparts a pink-red colour. The minimum lethal dose is ████████. ████████ can be readily bought via the ████████. For example, it is possibly to buy up to ████████ for a few pounds on ████████, without restriction. A chapter from Salts’, available ████████, describes the use of ████████ to commit suicide and compares it with ████████ and ████████.” (1) ████████ may be actively promoting a particular method of death by suicide and hence breaking the criminal law by assisting suicide. (2) That such a lethal substance ████████ should be so freely available on a popular ████████ ████████, sold by a company (████████) under the guise of being a meat preservative. ”
Source location
Jason THOMPSON · Prevention of Future Deaths report
Page 1 · concerns
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
Continue implementing suicide-prevention strategy and cross-government workplan measures to reduce access to suicide methods and harmful online content.

Verbatim wording from the response
“We continue to take action to reduce suicide rates through the Suicide Prevention Strategy for England¹ and the first Cross-Government Suicide Prevention Workplan², which sets out an ambitious programme across national and local government and the NHS. The Workplan include actions to reduce access to the means of suicide, including through harmful online content.”

Source location
2020-0246-Response-from-Dept.-of-Health-Social-Care-Redacted.pdf
Page 1 · response
Published 24 December 2020
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
Investigate available data on suicides using this method and identify steps to prevent further deaths from this and emerging methods.

Verbatim wording from the response
“I am advised that suicide prevention policy leads in the health system, at the Department of Health and Social Care, Public Health England (PHE), and NHS England and NHS Improvement (NHSEI), are alert to the risk posed by websites promoting suicide methods, and their direction on the use of certain chemicals in completing suicide, including the substance taken by Mr Thompson. These organisations, along with key stakeholders and academics, are looking at what data is available on suicides by this method and at what steps we can take to stop further loss of life by this method.”

Source location
2020-0246-Response-from-Dept.-of-Health-Social-Care-Redacted.pdf
Page 2 · response
Published 24 December 2020
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
Work with other government departments to explore further measures addressing this chemical and emerging suicide methods.

Verbatim wording from the response
“The concerns that Mr Thompson’s death raises sit within the policy remits of a range of Government departments, including the Department for Digital, Culture, Media and Sports (DCMS) for its work on online harms; and the Home Office (HO) for its work on the sale of reportable substances³. Officials have shared your concerns with those Departments and are working with officials from those and other Government departments to explore what further steps we can take to prevent further tragedies, both for this chemical, and any other emerging methods.”

Source location
2020-0246-Response-from-Dept.-of-Health-Social-Care-Redacted.pdf
Page 2 · response
Published 24 December 2020
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
Invite Home Office officials to brief NHS, public health and suicide-prevention partners on chemical-seller safeguards and specialist support for people at risk.

Verbatim wording from the response
“In addition to the cross-Government group set up to put in place steps to tackle emerging methods of suicide, officials at the Department of Health and Social Care have also invited HO officials to brief partners in NHSEI, PHE and suicide prevention stakeholders on what HO can do to ensure that sellers of these chemicals are aware of their potential use in suicide, and on what can be done to get specialist support to those who might be at risk.”

Source location
2020-0246-Response-from-Dept.-of-Health-Social-Care-Redacted.pdf
Page 3 · response
Published 24 December 2020
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
Withdraw Sodium Nitrite listings from Metalchem’s eBay sales.

Verbatim wording from the response
“I can confirm that Sodium Nitrite (which is used extensively in meat curing, preservation and in numerous chemical processes) is no longer sold by Metalchem on eBay. We withdrew the listing immediately back in April 2020 when we became aware that it was being recommended on these dreadful suicide forums for young people – notably ████████ – both of which are still sadly still active.”

Source location
2020-0246-Response-from-Metalchem-Ltd-Redacted.pdf
Page 1 · response
Published 24 December 2020
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 other online sellers to request removal of Sodium Nitrite listings where the purchase purpose cannot reasonably be ascertained.

Verbatim wording from the response
“I have since April proactively contacted a number of other sellers to request that they stop selling Sodium Nitrite NaNO2 (SN) online when clearly the reason for purchase cannot be reasonably ascertained. I have also enlisted the help of ████████ in removing a number of persistent sellers both on Ebay and then more recently this month on Etsy - and I regularly check these sites”

Source location
2020-0246-Response-from-Metalchem-Ltd-Redacted.pdf
Page 1 · response
Published 24 December 2020
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
Coordinate removal of persistent Sodium Nitrite sellers’ listings on eBay and Etsy.

Verbatim wording from the response
“I have since April proactively contacted a number of other sellers to request that they stop selling Sodium Nitrite NaNO2 (SN) online when clearly the reason for purchase cannot be reasonably ascertained. I have also enlisted the help of ████████ in removing a number of persistent sellers both on Ebay and then more recently this month on Etsy - and I regularly check these sites”

Source location
2020-0246-Response-from-Metalchem-Ltd-Redacted.pdf
Page 1 · response
Published 24 December 2020
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
Report the remaining Sodium Nitrite listing shipping to the United Kingdom for removal or restriction.

Verbatim wording from the response
“As of today (when I have just checked) I am pleased to say that there are no listings for Sodium Nitrite on either eBay or Etsy . It is however still available on ████████ with shipping to United Kingdom.”

Source location
2020-0246-Response-from-Metalchem-Ltd-Redacted.pdf
Page 2 · response
Published 24 December 2020
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
Prohibit the global sale of sodium nitrite as a chemical.

Verbatim wording from the response
“By way of background, in 2019 eBay took the voluntary decision to prohibit globally the sale of sodium nitrite as a chemical, after receiving a report of potential use of the substance for suicide attempts. In addition to updating our prohibited items policy, eBay updated its filters, which are used to help detect and prevent the listing for sale of this chemical.”

Source location
2020-0246-Response-from-Ebay-UK-Ltd-Redacted.pdf
Page 1 · response
Published 24 December 2020
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
Improve and continuously update filters and blocking algorithms to detect and prevent sodium nitrite listings.

Verbatim wording from the response
“By way of background, in 2019 eBay took the voluntary decision to prohibit globally the sale of sodium nitrite as a chemical, after receiving a report of potential use of the substance for suicide attempts. In addition to updating our prohibited items policy, eBay updated its filters, which are used to help detect and prevent the listing for sale of this chemical.”

Source location
2020-0246-Response-from-Ebay-UK-Ltd-Redacted.pdf
Page 1 · response
Published 24 December 2020
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
Continue working with relevant authorities to monitor developments and rigorously enforce the sodium nitrite prohibition.

Verbatim wording from the response
“However, please be assured that we will continue to work with the relevant authorities to keep abreast of developments and ensure that our policy prohibiting the sale of sodium nitrite as a chemical will continue to be enforced rigorously. As you will be aware, sodium nitrite in its pure form is still available for sale on the internet via other websites and platforms. We would therefore support stricter regulations restricting the online sale of sodium nitrite as a chemical in its pure form via the internet in order to prevent further such tragic cases in the future.”

Source location
2020-0246-Response-from-Ebay-UK-Ltd-Redacted.pdf
Page 2 · response
Published 24 December 2020
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
Online-harm concerns are assigned to DCMS, while concerns about sale of reportable substances are assigned to the Home Office.

Verbatim wording from the response
“The concerns that Mr Thompson’s death raises sit within the policy remits of a range of Government departments, including the Department for Digital, Culture, Media and Sports (DCMS) for its work on online harms; and the Home Office (HO) for its work on the sale of reportable substances³. Officials have shared your concerns with those Departments and are working with officials from those and other Government departments to explore what further steps we can take to prevent further tragedies, both for this chemical, and any other emerging methods.”

Source location
2020-0246-Response-from-Dept.-of-Health-Social-Care-Redacted.pdf
Page 2 · response
Published 24 December 2020
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
Curing salts may continue to be sold because their low sodium nitrite content and emetic effects make harmful ingestion less likely.

Verbatim wording from the response
“It is worth clarifying that sodium nitrite does occur as a legal ingredient in other products, such as meat curing salts. These were highlighted in recent press articles as being available on eBay. The amount of sodium nitrite in such products, at about 6%, is a small proportion of the overall product compared to the amount of sodium chloride, which is itself injurious to health if consumed in large quantities. Furthermore, the emetic effects of sodium chloride means that ingesting large amounts of curing salts is likely to make an individual vomit. Therefore, after taking advice, we have concluded that curing salts can continue to be sold on the site.”

Source location
2020-0246-Response-from-Ebay-UK-Ltd-Redacted.pdf
Page 2 · response
Published 24 December 2020
Open published response
25 Sep2020
East London
Concerns raised2
1. Lack of internet protections prohibiting the sale of DNP
2. Failure to prevent internet availability of DNP as diet pills
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Vaidotas Gerbutavicius · 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

Vaidotas Gerbutavicius, aged 21, ingested slimming pills containing 2,4-dinitrophenol after drinking alcohol and died in hospital on 10 March 2018. The report raised concerns that DNP remained readily available online, that existing legislation was inadequate, and that protections preventing its internet sale were absent.

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.
PFD Monitor interpretation
Lack of internet protections prohibiting the sale of DNP
Wider context from the report
“4. Prohibitions are in place on search engine algorithms used to prevent delivery of search results for TNT. 2, 4 – dinitrophenol is also used as an explosive, but there are no such internet protections in place to prohibit its sale. ”
Source location
Vaidotas Gerbutavicius · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to prevent internet availability of DNP as diet pills
Wider context from the report
“3. Evidence was given at the inquest that DNP is still readily available over the internet, as diet pills. ”
Source location
Vaidotas Gerbutavicius · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Lack of domestic restrictions on purchase of reportable substances

Sale of reportable substances at lethal purity and quantities

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Lack of specific seller guidance and training for one-off online marketplace purchases for self-harm

Failure to correctly evaluate small-quantity purchase patterns

Concerns raised2

Unrestricted domestic sale of the substances

Lack of consideration of controls on the quantities and purity in which the substances are sold

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8

Concerns raised2

Continued ease of public availability of the substance

Lack of business awareness that the substance is being obtained for suicide

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Availability of lethal quantities for internet purchase and UK delivery

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of restriction on the quantity of butane gas that can be purchased

Actions described in response 2

Respondent positions 1

Actions described in response 8

Actions described in response 3

Actions described in response 1

Respondent positions 1