9 Dec 2025 Stella Elizabeth LeClaire · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2
Advocacy of a substance for use in suicide View source Sale of a substance for suicide use View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stella Elizabeth LeClaire · 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
Stella Elizabeth LeClaire was found unresponsive in a Southwark hotel room on 30 July 2023 and was pronounced dead after taking a substance with the intention of ending her life. The report raises concerns about increasing requests for toxicological analysis involving the substance and whether blood toxicology should be obtained routinely in coroners’ investigations concerning poisoning.
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 Advocacy of a substance for use in suicide
Wider context from the report “2. I am also aware that in the last 5 years prevention of future death reports have been submitted from a number of other coroner areas. In broad terms the reasons for those reports are concerns that the substance is sold ████████ advocating its use in suicides ████████ method .
” Source location Stella Elizabeth LeClaire · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Sale of a substance for suicide use
Wider context from the report “2. I am also aware that in the last 5 years prevention of future death reports have been submitted from a number of other coroner areas. In broad terms the reasons for those reports are concerns that the substance is sold ████████ advocating its use in suicides ████████ method.
” Source location Stella Elizabeth LeClaire · Prevention of Future Deaths report
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 Restrict public access to the substance through targeted operational work with suppliers, platforms and manufacturers, including action against concerning online sales.
Verbatim wording from the response “A significant part of the group’s work has focused on limiting public access to the substance involved in this and other cases, and more than 30 targeted actions have been taken to reduce opportunities to obtain it for non-legitimate purposes. These include operational work with online suppliers, platforms and manufacturers to raise safeguarding concerns, restrict availability, and prevent its sale in particularly concerning ways, including on online forums. Government departments have also worked with online platforms to reduce opportunities for the substance to be purchased by individuals. We are also exploring opportunities to work with Border Force, using existing legal provisions, to improve detection of packages that may be linked to vulnerable individuals.” Source location 2025-0619 - Response from Department of Health and Social Care
Open published response
23 May 2025 Matthew Joseph O’Reilly · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1
Failure to evaluate small-quantity purchases for possible self-harm View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Matthew Joseph O’Reilly · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Matthew Joseph O’Reilly was found collapsed and unresponsive in his locked student accommodation room on 25 September 2020 and was pronounced dead after attempted resuscitation. Postmortem testing found recently ingested, significant and fatally toxic levels of a substance, and the inquest concluded that he died following deliberate self-ingestion, although his intentions remained unclear. The report raised concerns about gaps in guidance and oversight for the sale of a reportable poison, particularly through online marketplaces, and about public access to websites promoting poison-based suicide methods.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to evaluate small-quantity purchases for possible 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
Open source report
23 May 2025 William James Armstrong · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1
Failure to evaluate small-quantity purchases for indications of suicide or self-harm View source
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.
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 Failure to evaluate small-quantity purchases for indications of suicide or 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
Open source report
23 May 2025 Shaun Michael Bass · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1
Failure to evaluate small-quantity purchases for potential suicide or self-harm use View source
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.
×
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 Failure to evaluate small-quantity purchases for potential suicide or self-harm use
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
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess with DHSC and stakeholders whether additional regulation under the Poisons Act would be effective, proportionate and appropriately led.
Verbatim wording from the response “The Homeland Security Group oversee the Poisons Act for counter-terrorism purposes and works closely with other government departments in recognition that the legislation may also support wider public safety issues, including suicide prevention. My officials are working collaboratively with DHSC to assess whether, and how, the Poisons Act could play a meaningful role in reducing harm in this context. More generally, the Home Office keeps legislation under regular review to ensure it remains proportionate, evidence-based, and aligned with national security and public safety objectives.” Source location Response from Home Office
Open published response
23 May 2025 Andrew Alexander Roger BROWN · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2
Failure to evaluate small-quantity purchases for possible suicide or self-harm intent View source Incorrect evaluation of small-quantity purchases as recreational home-curing or food-preservation purchases View source
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.
×
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 Failure to evaluate small-quantity purchases for possible suicide or self-harm intent
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
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 Incorrect evaluation of small-quantity purchases as recreational home-curing or food-preservation purchases
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
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
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
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
Open published response
23 May 2025 Chantelle Williams · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2
Failure to evaluate small-quantity purchases for suicide or self-harm intent View source Failure to correctly evaluate increased small-quantity purchases for suicide or self-harm risk View source
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.
×
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 Failure to evaluate small-quantity purchases for suicide or self-harm intent
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
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to correctly evaluate increased small-quantity purchases for suicide or self-harm risk
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
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess with DHSC and stakeholders whether additional regulation under the Poisons Act would be effective, proportionate and appropriately led.
Verbatim wording from the response “The Homeland Security Group oversee the Poisons Act for counter-terrorism purposes and works closely with other government departments in recognition that the legislation may also support wider public safety issues, including suicide prevention. My officials are working collaboratively with DHSC to assess whether, and how, the Poisons Act could play a meaningful role in reducing harm in this context. More generally, the Home Office keeps legislation under regular review to ensure it remains proportionate, evidence-based, and aligned with national security and public safety objectives.” Source location Response from Home Office
Open published response
23 May 2025 Samuel David Dickenson · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1
Failure to evaluate small-quantity purchases for self-harm intent View source
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.
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 Failure to evaluate small-quantity purchases for self-harm intent
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
Open source report
23 May 2025 Mathew Anthony Price · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2
Failure to evaluate small-quantity purchases for suicide or self-harm indicators View source Failure to correctly evaluate small-quantity purchases for suicide or self-harm indicators View source
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
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 to evaluate small-quantity purchases for suicide or self-harm indicators
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
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to correctly evaluate small-quantity purchases for suicide or self-harm indicators
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
Open source report
23 May 2025 Kelly Michelle Walsh · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2
Failure to evaluate small-quantity purchases for deliberate self-harm View source Failure of Home Office guidance materials to address deliberate misuse for suicide or self-harm View source
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 Failure to evaluate small-quantity purchases for deliberate 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
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 misuse for suicide or 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
Open source report
14 Nov 2024 Hannah Mary AITKEN · Prevention of Future Deaths report Surrey
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Concerns raised 1
Unrestricted domestic sale of the substances View source
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.
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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.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unrestricted domestic sale of the substances
Wider context from the report “The Court heard anecdotal evidence from three Emergency Medical Consultants and others witnesses that in their direct experience, the use of ████████ for self-harm is increasing. However, none were aware of a central monitoring system which is able to record incidents of ████████ poisoning.
████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. There are no restrictions on the import of ████████ from abroad.
Since 2020, the Home Office has received at least five Prevention of Future Death Reports relating to ████████ The Home Secretary has recently provided reassurance in response to the Regulation 28 report relating to the death of Dr Jonathan Shaw that “the Home Office is actively exploring legislative and policy options, including working with or alongside officials of other Government Departments as appropriate, for the control of ████████ (and other similar substances)”.
The Home Office has clarified in evidence during this inquest that the policy objective of the Poisons Act 1972 is to control access to explosives precursors and poisons and to detect terrorist use of these substances to illicitly manufacture explosives or to cause harm to third parties. Prevention of suicide/self-harm is not a policy objective of the Home Office under this Act, and this falls under the remit of the Department for Health and Social Care. No evidence was provided that there is active consideration of controlling access to these substances to the general public, whether under the remit of the Home Office or any other Government department.
Whilst these substances have legitimate uses, including ████████ ████████ there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose.
- ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions ;
- ████████ can be purchased from abroad and imported to Great Britain with no restrictions;
████████
████████
- The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use, for example in ████████
- It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this.
Consideration should be given to whether any steps can be taken to address the above concerns.
” Source location Hannah Mary AITKEN · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen controls on reportable poisons, including suspicious-transaction reporting, online-marketplace obligations, and supplier personnel awareness requirements.
Verbatim wording from the response “The substance described in your report is a “reportable” poison listed in Part 4 of Schedule 1A of the Poisons Act. For the avoidance of doubt, this means that whilst it can be bought by members of the public, suspicious transactions need to be reported by retailers if there are questionable grounds for suspecting it is intended for any illicit use. The Poisons Act was amended in October 2023 to strengthen controls, and enhance our suspicious activity reporting requirements, including new obligations for online marketplaces. As well as the requirement to report suspicious transactions, economic operators supplying any reportable substances must now demonstrate that their personnel are aware about which of their products contain listed substances, and are instructed on their obligations.” Source location Response from the Home Office
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve retailer awareness of legal reporting duties and engage online platforms to encourage removal of pure-form sales and use of declarations of intended use.
Verbatim wording from the response “As your report captures, the Home Office is aware of the issues relating to this substance. My officials have been undertaking work across Government to both reduce access to this substance, and raise awareness to suppliers of the dangers of this substance. To this end, the Homeland Security Group (HSG) have been working to improve retailer awareness of their legal obligation to report suspicious activity for regulated and reportable substances.” Source location Response from the Home Office
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue work to ensure suppliers meet their obligations under the Poisons Act.
Verbatim wording from the response “Specifically, HSG have engaged with online platforms to encourage them to voluntarily remove the sale to individuals in its pure form. Government expertise in relation to substances of concern is also shared to inform retailer sales practices. This includes encouraging suppliers to use declaration of use forms for sales of such substances. This work will continue to ensure suppliers are meeting their requirements under the Poisons Act. Furthermore, if during the processing of suspicious activity reports a safeguarding concern is identified by Counter Terrorism Policing, consideration will be given to disseminating this intelligence to police forces to consider a welfare check.” Source location Response from the Home Office
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Concerning Methods Working Group to develop and deliver targeted actions reducing public access to emerging suicide methods.
Verbatim wording from the response “On methods of suicide specifically, Government departments have taken steps to reduce access to, and awareness of, this substance. DHSC leads a Concerning Methods Working Group to raise awareness of and tackle access to substances such as this one. The working group involves representatives from the voluntary, community and social enterprise sector, police, academics and the NHS, as well as Government departments including Department of Science, Innovation and Technology and the Home Office. The group develops and delivers rapid targeted actions to collectively reduce public access to emerging methods, including this one. Over 30 of the actions identified and implemented by the group have been to tackle this substance specifically.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with businesses, online suppliers and manufacturers to reduce non-legitimate purchasing and raise safeguarding awareness.
Verbatim wording from the response “The group has worked with businesses, including online suppliers and manufacturers of the substance, to reduce people’s ability to purchase it for non-legitimate purposes including suicide, and to raise awareness around safeguarding concerns with businesses where required. Government departments have also previously worked with manufacturers to reduce the lethality of the substance if ingested. This included work with online platforms to remove it from sale to individuals in its pure form. The group continues to work operationally with a range of organisations, and we are actively considering opportunities to work with the Border Force, using existing legal provisions, to help detect packages at the border which may be linked to vulnerable individuals and intended for suicide. The group’s actions are kept under review.” Source location Response from DHSC
Open published response
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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
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue operational work with organisations to reduce access to concerning methods.
Verbatim wording from the response “The group has worked with businesses, including online suppliers and manufacturers of the substance, to reduce people’s ability to purchase it for non-legitimate purposes including suicide, and to raise awareness around safeguarding concerns with businesses where required. Government departments have also previously worked with manufacturers to reduce the lethality of the substance if ingested. This included work with online platforms to remove it from sale to individuals in its pure form. The group continues to work operationally with a range of organisations, and we are actively considering opportunities to work with the Border Force, using existing legal provisions, to help detect packages at the border which may be linked to vulnerable individuals and intended for suicide. The group’s actions are kept under review.” Source location Response from DHSC
Open published response
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Includes promotion or advertising for suicide use, sale or supply for that use, intended-use enquiries, transaction assessment, suspicious-purchase evaluation or reporting, quantity controls and end-user controls.
