Recurring concern

Inadequate controls for sodium nitrite poisoning risks

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First reported 29 Jul 2021•Latest report 9 Jul 2025

Definition

What this concern includes

Includes failures of controls specifically dedicated to preventing, detecting or responding to sodium nitrite poisoning risks, including dissemination of current risk information to relevant practitioners, monitoring of poisoning incidents, and regulation or control of hazardous purity or quantities.

Not included

Excludes generic failures to disseminate policies, guidance or learning where sodium nitrite poisoning is not the specific hazard.
Excludes unrelated risks from other nitrites, chemicals or medicines unless the report explicitly ties them to sodium nitrite poisoning.
Excludes generic mental health information-sharing, substance monitoring or product-safety deficiencies without a direct sodium nitrite poisoning connection.
Excludes factual descriptions of sodium nitrite exposure or poisoning where no deficient or unreliable safety control is identified.

Reports: 3
Individual concerns: 5
Date range: 2021–2025
Stated actions: 4

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 Care3

Home Office2

Public Health England1

Royal College of Psychiatrists1

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 raised1
1. Lack of central monitoring of sodium nitrite poisoning incidents
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

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 central monitoring of sodium nitrite poisoning incidents
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
14 Nov2024
Surrey
Concerns raised2
1. Lack of central monitoring of poisoning incidents involving 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 3
1. Action
  Monitor trends in the substance and other concerning methods using intelligence from multiple sources, including national statistics and local organisations.
  Stated by Department of Health and Social CareStated completed
2. 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
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
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
Lack of central monitoring of poisoning incidents involving 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
Monitor trends in the substance and other concerning methods using intelligence from multiple sources, including national statistics and local organisations.

Verbatim wording from the response
“You also raised the issue of monitoring. The Department monitors trends of this substance and other concerning methods as part of the working group. We have approaches in place to collect intelligence from a wide range of sources. We use Office for National Statistics data, and we are exploring how to make better use of national near real time suspected suicide surveillance data to make sure we can identify and respond to trends more quickly. Regional Leads within the Office for Health Improvement and Disparities also pass on information from local organisations to central teams for monitoring. Whilst we observed an increase in the number of suicides using this method a few years ago, we have not found concrete evidence that the numbers have increased in the last few years, and since the Concerning Methods Working Group was set up.”

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
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
29 Jul2021
Cambridgeshire and Peterborough
Concerns raised2
1. Lack of national guidance and timely information for mental health practitioners about sodium nitrate/nitrite risks
2. Failure to disseminate information about sodium nitrate/nitrite risks beyond immediately involved colleagues
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 1
1. Action
  Identify opportunities to communicate broader risk advice to psychiatrists about exploring and responding to patients’ medication and substance use or access.
  Stated by Royal College of PsychiatristsStated planned
Respondent positions 1
1. Position
  National data do not identify sodium nitrate as a noted contributory factor in suicide deaths.
  Stated by Royal College of PsychiatristsDisputes the concern
AI-generated summary

JAMES MICHAEL NOWSHADI · 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

James Michael Nowshadi died after ingesting a substance he had obtained online to end his life, suffering cardiac arrest and being pronounced dead on 1 April 2020. Concerns included insufficient national guidance and information-sharing about the risks of sodium nitrate/nitrite, missed opportunities for learning from the Serious Incident Review, and a lack of guidance for emergency clinicians on the use of methylene blue in cases involving cardiac arrest.

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 national guidance and timely information for mental health practitioners about sodium nitrate/nitrite risks
Wider context from the report
“1. There does not appear to be any national guidance available to psychiatrists and mental health practitioners dealing with possible ████████ cases. Those involved in James’ care made insufficient effort to research or evaluate the potential risks and consequences of James obtaining and using the ████████ to end his life and any information that was obtained from brief internet searches was not disseminated to colleagues beyond those immediately involved in James’ care only. I am concerned that there is a risk of future fatalities if mental health practitioners do not have ready access to timely and up-to-date information about the risks associated with sodium nitrate/nitrite. ”
Source location
JAMES MICHAEL NOWSHADI · 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 disseminate information about sodium nitrate/nitrite risks beyond immediately involved colleagues
Wider context from the report
“1. There does not appear to be any national guidance available to psychiatrists and mental health practitioners dealing with possible ████████ cases. Those involved in James’ care made insufficient effort to research or evaluate the potential risks and consequences of James obtaining and using the ████████ to end his life and any information that was obtained from brief internet searches was not disseminated to colleagues beyond those immediately involved in James’ care only. I am concerned that there is a risk of future fatalities if mental health practitioners do not have ready access to timely and up-to-date information about the risks associated with sodium nitrate/nitrite. ”
Source location
JAMES MICHAEL NOWSHADI · 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
Identify opportunities to communicate broader risk advice to psychiatrists about exploring and responding to patients’ medication and substance use or access.

Verbatim wording from the response
“Where we think the College can have more direct effect is ensuring psychiatrists understand how to effectively explore and respond to issues associated with medications and substances that they are aware their patients are taking or have access to. It is crucial that clinicians use any such information, provided by the patient or elsewhere and make an evaluation of risk, taking action where needed. In reinforcing some of the key risk advice around this, we can specifically refer to ████████ but hope you will agree it would be good to focus on this in a broader way to support the impact of any such communication. We will look for opportunities to do this in the near future.”

Source location
Response from Royal College of Psychiatrists
Page 2 · response
Published 3 August 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
National data do not identify sodium nitrate as a noted contributory factor in suicide deaths.

Verbatim wording from the response
“On reviewing national data associated with deaths by suicide, we have not been able to identify ████████ as a noted contributory factor to these tragic incidents. We would welcome any additional information that might be available on this particular substance and its role in any deaths. We are happy to raise this matter with those bodies who have responsibility for such data reporting and collection, although appreciate it might have already directly related it with them.”

Source location
Response from Royal College of Psychiatrists
Page 2 · response
Published 3 August 2021
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of central monitoring of sodium nitrite poisoning incidents

Concerns raised2

Lack of central monitoring of poisoning incidents involving 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.3

Concerns raised2

Lack of national guidance and timely information for mental health practitioners about sodium nitrate/nitrite risks

Failure to disseminate information about sodium nitrate/nitrite risks beyond immediately involved colleagues

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

Actions described in response 3

Actions described in response 1

Respondent positions 1