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

Distinct published reports

Individual concerns
22

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
36

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

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.

  1. Worcestershire

    AI-generated summary

    Bethany Victory Shipsey · 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 Victory Shipsey, a young woman with significant mental health difficulties, died by suicide on 15 February 2017 after deliberately ingesting tablets containing dinitrophenol purchased over the Internet. The report identified significant failings in hospital monitoring and supportive care, and raised concern that dinitrophenol was extremely toxic, had no known antidote, and was freely available online.

    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 internet availability of dinitrophenol

    Wider context from the report

    “(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. (2) (3) ”

    Source location

    Bethany Victory Shipsey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Manchester West

    AI-generated summary

    Catherine Mary Findlay · 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

    Catherine Mary Findlay, aged 37, was found unresponsive and not breathing at her home on 24 May 2015 and was pronounced dead by paramedics. The post-mortem and inquest attributed her death to Methoxyphenidine (MXP) and cocaine toxicity. The report raised concerns that MXP was freely available online as a “research chemical” despite being misused and potentially life-threatening, and requested a review of its status and control.

    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

    Uncontrolled internet availability of research chemicals

    Wider context from the report

    “2. MXP is not a controlled substance but related to Ketamine (a dis-associative anaesthetic) and is thought to be a replacement for another substance – Methoxetomine – which is now a controlled substance under the Misuse of Drugs Act. 3. I have concerns that such substances - freely marketed as “research chemicals” are generally available over the internet. They are sold with a warning that they are not for human consumption but are misused and consumed by people and are consequently dangerous and potentially life threatening. ”

    Source location

    Catherine Mary Findlay · 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

    Introduce the Psychoactive Substances Bill to establish a blanket ban on supplying psychoactive substances for human consumption.

    Verbatim wording from the response

    “On 28 May, we introduced the Psychoactive Substances Bill to create a blanket ban on the supply of New Psychoactive Substances (NPS). This landmark Bill will ban the sale, supply, production and distribution of psychoactive substances for human consumption, including MXP, and give police and local authorities greater powers to tackle this reckless trade.”

    Source location

    2015-0372-Response
    Page 1 · response
    Published 13 October 2015

    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 internet providers to ensure compliance with laws governing online drug advertising and sales.

    Verbatim wording from the response

    “The Government and law enforcement agencies take the issue of unlawful advertising and sales of drugs on the internet very seriously, and we continue to work with internet providers to ensure that they comply with the law. This can”

    Source location

    2015-0372-Response
    Page 1 · response
    Published 13 October 2015

    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

    Develop international partnerships and regulatory cooperation to address overseas websites trading controlled drugs and emerging supply threats.

    Verbatim wording from the response

    “Considerable illegal activity takes place on the internet outside of UK jurisdiction. The UK continues to work with international partners to develop an effective response to the supply of controlled drugs and to react swiftly to emerging threats. In order to tackle illegally trading websites identified overseas, we are building strong partnerships with international partners. There is also ongoing work with the EU and other international regulatory agencies to ensure that, wherever possible, offending websites are amended to comply with the law.”

    Source location

    2015-0372-Response
    Page 2 · response
    Published 13 October 2015

    Open published response

  3. Cardiff & the Vale of Glamorgan

    AI-generated summary

    Thaker Jamal Hafid · 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

    Thaker Jamal Hafid was found unresponsive by his wife at home on 9 February 2015 and was confirmed deceased at the scene. Post-mortem testing found Acetylfentanyl, an unlicensed and highly potent opioid that he had apparently ordered online to help wean himself off heroin; the report raised concern that its availability could lead to further deaths.

    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 potent and toxic acetylfentanyl through legal marketing and the internet

    Wider context from the report

    “(1) Post Mortem testing on blood taken from the deceased found the presence of Acetylfentanyl (opioid analgesic drug more potent than heroin or morphine and fentanyl) and is not licensed for medicinal use and has only been sold illegally as a “designer drug”. This drug is being marketed legally and is available over the internet. The evidence in this case indicated that the deceased had ordered it with a view to weaning himself off heroin. Such is the potency/toxicity of this drug and the apparent free availability of it, it is likely that further deaths may occur due to it’s use. It is believed that this was the first known death in the UK caused by or contributed to by this drug. ”

    Source location

    Thaker Jamal Hafid · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Leicester City and South Leicestershire

    AI-generated summary

    Brenda Kathryn Gabrielle Leyland · 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

    Brenda Leyland was found deceased in a hotel room on 4 October 2014 after buying helium canisters to end her life; the inquest concluded suicide. The concerns were the free availability of helium canisters, the lack of controls on purchase quantities, their large volume, and the absence of a modified control valve to restrict gas release.

    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 controls on individual helium canister purchase quantities

    Wider context from the report

    “(1) That helium gas is freely available in canisters and there appears to be no controlling measures on how many canisters can be bought by an individual. (2) The size of the helium canisters are of large volume. (3) There is no modified control valve attached to the canisters which would restrict the volume of gas being released. ”

    Source location

    Brenda Kathryn Gabrielle Leyland · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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

    Evidence that even small amounts of helium can cause death means controls on availability would be ineffective.

    Verbatim wording from the response

    “Having reviewed the response in the case of Matthew Satterthwaite, which was sent to HM Coroner Mr Nigel Meadows, I note that the examples given showed that even small amounts of helium can be sufficient to cause death, rendering controls on availability ineffective. This has led to a number of options to address the issues you raise being considered and discarded.”

    Source location

    2015-0112-Response-by-Department-of-Health
    Page 1 · response
    Published 20 March 2015

    Open published response

  5. Manchester North

    AI-generated summary

    Sindy Louise Woodhall · 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

    Sindy Louise Woodhall had longstanding addictions to alcohol and butane and propane, which she misused regularly. She was found collapsed in the street on 24 October 2013, was taken to hospital, and subsequently died; the concerns included the sale of large amounts of potentially fatal gases to her by retailers aware of her addiction, along with lack of regulation and limited Trading Standards powers.

    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 regulation of the sale of large amounts of toxic or potentially fatal gases

    Wider context from the report

    “1. During the course of the inquest, it transpired that cans of the aforementioned gases were being sold to the deceased by local retailers who were fully aware of her addiction/problems. Whilst morally reprehensible, there was no law to prevent them from selling large amounts of the toxic/potentially fatal gases to the deceased. 2. Lack of regulation. ”

    Source location

    Sindy Louise Woodhall · 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 Trading Standards powers to take action or prosecute

    Wider context from the report

    “3. No powers afforded to Trading Standards to take action/prosecute. ”

    Source location

    Sindy Louise Woodhall · 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

    Work with the Department of Health to support restrictions on inappropriate access to volatile substances.

    Verbatim wording from the response

    “We share your concern about abuse of volatile substances (VSA) such as butane and propane and have been working with the Department of Health to support their efforts to restrict inappropriate access to these products. A large number of retailers already restrict access to butane lighter refills and some have committed to restricting the sale of multiple canisters in one transaction. The Association of Convenience Stores (ACS) was asked by the public health minister last year to urge its members to remove accessible displays and restrict sales to one can per customer. ACS reassured the minister that its members already had policies in place to restrict access to butane.”

    Source location

    2014-0292-Response-by-Public-Health-England
    Page 1 · response
    Published 1 July 2014

    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 to support efforts to restrict inappropriate access to volatile substances.

    Verbatim wording from the response

    “We share your concern about abuse of volatile substances (VSA) such as butane and propane and have been working with the Department of Health to support their efforts to restrict inappropriate access to these products. A large number of retailers already restrict access to butane lighter refills and some have committed to restricting the sale of multiple canisters in one transaction. The Association of Convenience Stores (ACS) was asked by the public health minister last year to urge its members to remove accessible displays and restrict sales to one can per customer. ACS reassured the minister that its members already had policies in place to restrict access to butane.”

    Source location

    2014-0292-Response-by-Department-of-Health
    Page 3 · response
    Published 1 July 2014

    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 private professional body has no powers to become involved in this matter.

    Verbatim wording from the response

    “I would like to take this opportunity to advise you that the Trading Standards Institute is a private company and professional body for trading standards officers, as such this matter is not something that we are able to get involved with as we have no powers, this would be a matter for trading standards departments that are run by local authorities.”

    Source location

    2014-0292-Response-by-Trading-Standards-Institute
    Page 1 · response
    Published 1 July 2014

    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 this matter rests with trading standards departments run by local authorities.

    Verbatim wording from the response

    “I would like to take this opportunity to advise you that the Trading Standards Institute is a private company and professional body for trading standards officers, as such this matter is not something that we are able to get involved with as we have no powers, this would be a matter for trading standards departments that are run by local authorities.”

    Source location

    2014-0292-Response-by-Trading-Standards-Institute
    Page 1 · response
    Published 1 July 2014

    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

    Trading Standards lacks powers to act against retailers selling these products, except where sales to children constitute an offence.

    Verbatim wording from the response

    “The Council was very sorry to note the death of Sindy under such circumstances. As outlined in your notice your concerns were around the lack of regulation or powers afforded to Trading Standards to take any action against a retailer who, in full knowledge of the addition in this matter, still sold products to her. Whilst it is an offence to sell to a child there are no other powers that we have to take any action. There is also no licensing regime in place to register or licence traders of such products, other than alcohol, and therefore we do not know who sells it.”

    Source location

    2014-0292-Response-by-Oldham-Council
    Page 1 · response
    Published 1 July 2014

    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

    Legislative action to regulate these products is a matter for the Department for Business, Innovation and Skills to consider.

    Verbatim wording from the response

    “I trust the letter you have written to the Department for Business, Innovation and Skills may prompt them to consider legislating in this area.”

    Source location

    2014-0292-Response-by-Oldham-Council
    Page 1 · response
    Published 1 July 2014

    Open published response

  6. Wiltshire and Swindon

    AI-generated summary

    Christopher Michael SCOTT · 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

    Christopher Michael SCOTT took pills containing AMT on 21 July 2013 and was admitted to hospital on 22 July 2013. He died on 24 July 2013 after developing multiorgan failure and bronchopneumonia attributable to the toxic effects of AMT. The principal concern was that AMT was a readily available legal drug whose effects could be deadly, with other deaths also appearing to involve AMT.

    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 AMT through the internet and community

    Wider context from the report

    “(1) During the course of the evidence I read out a toxicology report that referred to other deaths involving AMT. I exhibited 2 Internet research results that related to other AMT deaths. Slightly unconventionally I exhibited these internet results as ‘C2’ and ‘C3’ (copies attached) to further support this report with a view to the prevention of future deaths. The first report ‘C2’ referred to the death of Adam Weeks in November 2011. His Inquest in March 2012 confirmed his death due to AMT intoxication and whilst the report makes reference to the Coroner writing to appropriate authorities prior to Christopher's inquest I did speak with that Coroner who indicated that he had not make such a report (r43 report under the Coroners Rules 1984). Document ‘C3’ refers to three other deaths in respect of which AMT appears to have been involved during 2012 and 2013. As it stands at the moment AMT is a “legal high” and I am concerned that as it is currently a legal drug that it is readily available to be purchased for example over the internet and in the community at large. The effects of AMT can vary from person to person but clearly the effects can be deadly as the examples show including of course Christopher's death. ”

    Source location

    Christopher Michael SCOTT · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026