Recurring concern

Failure to ensure substance vendors recognise suicide and self-harm misuse risks

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First reported 30 Jul 2024•Latest report 23 May 2025

Definition

What this concern includes

Includes failures in arrangements intended to ensure vendors and suppliers of the substance recognise, understand and act on its potential suicide or self-harm misuse, including relevant guidance, training, warnings and vendor-facing awareness controls.

Not included

Excludes generic public awareness, suicide-prevention education or mental-health support that is not directed to vendors or suppliers of the substance.
Excludes failures to assess or report individual suspicious transactions where vendor awareness of suicide or self-harm misuse is not the shared unsafe condition.
Excludes regulation of other hazardous substances unless the assertion concerns the same vendor-awareness condition for the substance.
Excludes product access, quantity controls, packaging, transaction screening and online-sale safeguards when the assertion does not identify vendor recognition or awareness as the deficient control.

Reports: 9
Individual concerns: 21
Date range: 2024–2025
Stated actions: 2

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.

Home Office8

Department for Science, Innovation and Technology1

Department of Health and Social Care1

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.

23 May2025
Manchester West
Concerns raised3
1. Lack of specific seller guidance and training for one-off online marketplace purchases for self-harm
2. Lack of vendor awareness of potential self-harm misuse
3. Lack of vendor awareness of website distribution on suicide-promotion platforms
This report raised 6 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.
Respondent positions 1
1. Position
  Online suicide and self-harm forum regulation falls within DSIT’s responsibility under the Online Safety Act, working with Ofcom.
  Stated by Home OfficeRedirects responsibility
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
Lack of vendor awareness of potential self-harm misuse
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
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 vendor awareness of website distribution on suicide-promotion platforms
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
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 suicide and self-harm forum regulation falls within DSIT’s responsibility under the Online Safety Act, working with Ofcom.

Verbatim wording from the response
“Finally, I understand the troubling concerns you have raised about the pro-suicide forums. DSIT, as the department responsible for the Online Safety Act, is committed to working with Ofcom and bereaved families. This partnership aims to ensure the Act protects all users from illegal suicide and self-harm content and shields children from harmful material that does not meet the criminal threshold.”

Source location
Response from Home Office
Page 3 · response
Published 4 June 2025
Open published response
23 May2025
Manchester West
Concerns raised2
1. Lack of vendor awareness of the substance’s potential misuse for suicide or self-harm
2. Lack of specific guidance and training for sellers on one-off online-marketplace purchases for self-harm
This report raised 5 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

William James Armstrong · 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

William James Armstrong, aged 24, died after deliberately self-administering a significant quantity of a toxic substance following its internet purchase. He was found unresponsive in a hotel room after an ambulance response delay, and the report states that the consequence of the delay cannot be established. Concerns included gaps in guidance and training for sellers of the substance, the assessment of small-quantity purchases as legitimate use, and public access to websites promoting poisons and 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 vendor awareness of the substance’s potential misuse for suicide or self-harm
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 the ████████ 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. ”
Source location
William James Armstrong · 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 specific guidance and training for sellers on 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 to 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-harming. 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, fertiliser 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
William James Armstrong · Prevention of Future Deaths report
Page 2 · concerns
Open source report
23 May2025
Manchester West
Concerns raised2
1. Lack of specific seller guidance and training on deliberate suicide or self-harm misuse of the substance
2. Lack of vendor awareness of the substance’s potential suicide or self-harm misuse
This report raised 3 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

Shaun Michael Bass · 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

Shaun Michael Bass, aged 23, was found collapsed and unresponsive at his residence on 23 February 2020 after ingesting a fatal quantity of sodium nitrate/nitrite. The report identified concerns about gaps in continuity of mental healthcare, a missed mental health assessment review, inadequate responses to family concerns, and the availability and online promotion of reportable poisons for 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
Lack of specific seller guidance and training on deliberate suicide or self-harm misuse of the substance
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 to sellers, particularly ████████ acquired by members of the public, particularly over ‘on-line marketplaces’ in circumstances of the purchase on a ‘one off’ basis for the means of self-harming. 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
Shaun Michael Bass · 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 vendor awareness of the substance’s potential suicide or self-harm misuse
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 the ████████ 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
Shaun Michael Bass · Prevention of Future Deaths report
Page 2 · concerns
Open source report
23 May2025
Manchester West
Concerns raised3
1. Lack of specific guidance and suggested training for sellers about one-off online purchases for self-harm
2. Lack of vendor awareness of the substance’s potential suicide or self-harm misuse
3. Failure of Home Office guidance materials to address deliberate suicide or self-harm misuse of the substance
This report raised 6 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
  Engage online platforms and retailers to encourage voluntary removal of pure-form substances and vigilance for purchases linked to self-harm or suicide.
  Stated by Home OfficeStated completed
2. Action
  Improve supplier awareness of suspicious-activity reporting obligations and promote safer sales practices, including declaration-of-use forms.
  Stated by Home OfficeStated in progress
Respondent positions 1
1. Position
  Individual substances are not routinely highlighted in guidance because doing so could draw widespread attention; existing general controls and targeted engagement are relied upon.
  Stated by Home OfficeExisting arrangements considered sufficient
AI-generated summary

Andrew Alexander Roger BROWN · 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 Alexander Roger BROWN was found collapsed and unresponsive at his residence on 9 August 2023 and was pronounced dead after paramedics attended. The cause of death was toxicity from a self-administered poison, although his intentions remained unclear. Concerns included gaps in guidance for online sellers and the public regarding suspicious purchases and the potential use of the poison for suicide or self-harm, as well as access to websites providing information about obtaining and administering poisons.

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 guidance and suggested training for sellers about one-off online 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 to sellers, particularly ████████ acquired by members of the public, particularly over ‘on-line marketplaces’ in circumstances of the purchase on a ‘one off’ basis for the means of self-harming. 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
Andrew Alexander Roger BROWN · 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 vendor awareness of the substance’s potential suicide or self-harm misuse
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 ████████ 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 the ████████ 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. ”
Source location
Andrew Alexander Roger BROWN · 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 of Home Office guidance materials to address deliberate suicide or self-harm misuse of the substance
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 to sellers, particularly ████████ acquired by members of the public, particularly over ‘on-line marketplaces’ in circumstances of the purchase on a ‘one off’ basis for the means of self-harming. 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
Andrew Alexander Roger BROWN · 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
Engage online platforms and retailers to encourage voluntary removal of pure-form substances and vigilance for purchases linked to self-harm or suicide.

Verbatim wording from the response
“The substances in question are not routinely individually highlighted within government issued guidance in relation to their potential misuse for self-harm or suicide. This is to avoid bringing widespread attention to them. However, 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 retailer sales practices. For example, we encourage suppliers to use declaration of use forms for sales of potentially harmful substances.”

Source location
Response from the Home Office
Page 2 · response
Published 4 June 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
Improve supplier awareness of suspicious-activity reporting obligations and promote safer sales practices, including declaration-of-use forms.

Verbatim wording from the response
“The substances in question are not routinely individually highlighted within government issued guidance in relation to their potential misuse for self-harm or suicide. This is to avoid bringing widespread attention to them. However, 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 retailer sales practices. For example, we encourage suppliers to use declaration of use forms for sales of potentially harmful substances.”

Source location
Response from the Home Office
Page 2 · response
Published 4 June 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
Individual substances are not routinely highlighted in guidance because doing so could draw widespread attention; existing general controls and targeted engagement are relied upon.

Verbatim wording from the response
“The substances in question are not routinely individually highlighted within government issued guidance in relation to their potential misuse for self-harm or suicide. This is to avoid bringing widespread attention to them. However, 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 retailer sales practices. For example, we encourage suppliers to use declaration of use forms for sales of potentially harmful substances.”

Source location
Response from the Home Office
Page 2 · response
Published 4 June 2025
Open published response
23 May2025
Manchester West
Concerns raised2
1. Lack of vendor awareness of suicide or self-harm misuse
2. Failure of seller guidance and training to address deliberate suicide or self-harm misuse of reportable chemicals
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.

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

Chantelle Williams · 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

Chantelle Williams was found collapsed and unresponsive in her room on Keats Ward on 29 May 2020 and could not be resuscitated. Post-mortem analysis identified fatally toxic levels of two substances, likely from a batch she had previously sourced, retained and hidden. The report raises concerns about the online sale and regulation of reportable poisons, the failure to identify suspicious purchases for self-harm or suicide, and websites providing information about obtaining and using poisons to cause death.

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 vendor awareness of suicide or self-harm misuse
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 or 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. ”
Source location
Chantelle Williams · 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 of seller guidance and training to address deliberate suicide or self-harm misuse of reportable chemicals
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 to 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-harming. 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
Chantelle Williams · Prevention of Future Deaths report
Page 2 · concerns
Open source report
23 May2025
Manchester West
Concerns raised3
1. Lack of specific seller guidance and training on one-off online purchases for self-harm
2. Lack of vendor awareness of potential self-harm misuse
3. Home Office guidance materials failing to address deliberate suicide and self-harm misuse
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.

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

Samuel David Dickenson · 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

Samuel David Dickenson died after ingesting a substance acquired over the internet and was confirmed dead in hospital on 11 March 2020. The concerns relate to gaps in guidance and oversight of online sales of reportable poisons, including the failure to identify or address purchases intended for suicide or self-harm, and the availability of online information promoting access to poisons and methods of administration.

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 on one-off online 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 to sellers, particularly Sodium Nitrate/Nitrite 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-harming. 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
Samuel David Dickenson · 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 vendor awareness of potential self-harm misuse
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 the ████████ 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 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
Samuel David Dickenson · 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
Home Office guidance materials failing to address deliberate suicide and self-harm misuse
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 to sellers, particularly Sodium Nitrate/Nitrite 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-harming. 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
Samuel David Dickenson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
23 May2025
Manchester West
Concerns raised3
1. Failure of Home Office guidance materials to address deliberate suicide or self-harm misuse of the substance
2. Lack of vendor awareness of the substance's potential suicide or self-harm misuse
3. Lack of specific guidance and suggested training for sellers of the substance through online marketplaces
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.

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

Mathew Anthony Price · 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

On 28 June 2021, Mathew Anthony Price was found collapsed and unresponsive at his residence after consuming a significant and fatally toxic quantity of a substance. The report identifies concerns about the sale and purchase of the substance, including inadequate guidance for sellers and the failure to recognise small-quantity purchases as potential self-harm risks. It also describes online access to information about poisons and methods of suicide.

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 of Home Office guidance materials to address deliberate suicide or self-harm misuse of the substance
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 to sellers, particularly ████████ acquired by members of the public, particularly over ‘online marketplaces’ in circumstances of the purchase on a ‘one off’ basis of the means of self-harming. 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
Mathew Anthony Price · 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 vendor awareness of the substance's potential suicide or self-harm misuse
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 this 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 the ████████ 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. ”
Source location
Mathew Anthony Price · 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 specific guidance and suggested training for sellers of the substance through online marketplaces
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 to sellers, particularly ████████ acquired by members of the public, particularly over ‘online marketplaces’ in circumstances of the purchase on a ‘one off’ basis of the means of self-harming. 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
Mathew Anthony Price · Prevention of Future Deaths report
Page 2 · concerns
Open source report
23 May2025
Manchester West
Concerns raised2
1. Lack of specific guidance or training for sellers on one-off online-marketplace purchases for self-harm
2. Lack of vendor awareness of potential self-harm misuse
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

Kelly Michelle Walsh · 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

Kelly Michelle Walsh was discovered dead at her residence on 27 February 2021 after ingesting a fatally toxic substance obtained from an internet-based supplier. The report raised concerns about insufficient guidance for online sellers and the failure to identify suspicious small-quantity purchases that may be intended for self-harm. It also identified online access to information about obtaining and using poisons to end 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 specific guidance or training for sellers on 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 to 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-harming. 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
Kelly Michelle Walsh · 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 vendor awareness of potential self-harm misuse
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 lest 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 the ████████ 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-couring/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. ”
Source location
Kelly Michelle Walsh · Prevention of Future Deaths report
Page 2 · concerns
Open source report
30 Jul2024
Nottinghamshire
Concerns raised1
1. Lack of business awareness that the substance is being obtained for suicide
This report raised 5 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

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
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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised3

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

Lack of vendor awareness of potential self-harm misuse

Lack of vendor awareness of website distribution on suicide-promotion platforms

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 vendor awareness of the substance’s potential misuse for suicide or self-harm

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

Concerns raised2

Lack of specific seller guidance and training on deliberate suicide or self-harm misuse of the substance

Lack of vendor awareness of the substance’s potential suicide or self-harm misuse

Concerns raised3

Lack of specific guidance and suggested training for sellers about one-off online purchases for self-harm

Lack of vendor awareness of the substance’s potential suicide or self-harm misuse

Failure of Home Office guidance materials to address deliberate suicide or self-harm misuse of the substance

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 vendor awareness of suicide or self-harm misuse

Failure of seller guidance and training to address deliberate suicide or self-harm misuse of reportable chemicals

Concerns raised3

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

Lack of vendor awareness of potential self-harm misuse

Home Office guidance materials failing to address deliberate suicide and self-harm misuse

Concerns raised3

Failure of Home Office guidance materials to address deliberate suicide or self-harm misuse of the substance

Lack of vendor awareness of the substance's potential suicide or self-harm misuse

Lack of specific guidance and suggested training for sellers of the substance through online marketplaces

Concerns raised2

Lack of specific guidance or training for sellers on one-off online-marketplace purchases for self-harm

Lack of vendor awareness of potential self-harm misuse

Respondent positions 1

Actions described in response 2

Respondent positions 1