4 Nov 2025 Oliver Luke Gorman · Prevention of Future Deaths report Manchester South
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Concerns raised 5 Inadequate visibility and wording of aerosol inhalation warnings View source Failure of social media platforms to control dangerous challenge content View source Lack of age restrictions on aerosol products and other products containing butane/propane propellant View source Failure to control toxic social media algorithms View source Age restrictions for social media platforms failing to account for hazardous content exposure View source See 2 more concerns
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 3
Action
Write to social media companies to raise awareness of aerosol misuse and encourage removal of dangerous content.
View source
Action
Promote existing and updated caution labels and encourage aerosol marketers to adopt them across products placed on the UK market.
View source
Action
Developed and updated guidance for a prominent inhalation caution mark, including revised wording, placement and visibility specifications.
View source
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AI-generated summary
Oliver Luke Gorman · 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
Oliver Luke Gorman, aged 12, died at home on 5 May 2025 after inhaling butane gas from an aerosol spray. The report raised concerns about the lack of age restrictions on some products containing butane or propane, the adequacy of warnings about inhalation risks, and social media content promoting dangerous challenges.
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. The report was sent to British Aerosol Manufacturers' Association; that does not assign responsibility.
PFD Monitor interpretation Inadequate visibility and wording of aerosol inhalation warnings
Wider context from the report “2. Adequacy of Warning
The warnings on the cans of ████████ of the danger/risk of inhaling the aerosol spray were, in my opinion, inadequate in terms of visibility and wording.
The warning was set in an area outline of about 12mm x 12mm, in black or white writing depending on the background colour of the can. It was lost amongst all the other information and writing on the can. At least the ‘inflammable content’ warning was outlined in red.
The warning stated “SOLVENT ABUSE CAN KILL INSTANTLY”.
Many people (both adults and children) may not equate inhalation of aerosol spray with solvent abuse. Thus, the warning does not appear to properly describe the risks of using/misusing using the product. That risk being inhalation of this aerosol spray can cause instant death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Aerosol Manufacturers' Association; that does not assign responsibility.
PFD Monitor interpretation Failure of social media platforms to control dangerous challenge content
Wider context from the report “3. Social media content and access
The posting of challenges such as those listed above, and no doubt others, on social media platforms will continue to take the lives of young, impressionable and/or vulnerable children/teenagers unless the platform providers take responsibility fortheir content and/or toxic algorithms either voluntarily or through Government action. The former seems unlikely.
Further the age restriction of 13 years for most social media platforms appears to have been determined in relation to data protection laws rather than of the nature of the content to which they will be exposed, again via any toxic algorithms or any searches they may make.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Aerosol Manufacturers' Association; that does not assign responsibility.
PFD Monitor interpretation Lack of age restrictions on aerosol products and other products containing butane/propane propellant
Wider context from the report “1. No Age Restriction
The age restriction on the purchase of butane for refilling cigarette lighters (and the like) is 18 years of age. I understand the legislation is primarily aimed at preventing the misuse of butane.
The age restriction on the purchase of aerosol paints is 16 years of age. I understand that the legislation is aimed at reducing incidents of graffiti and preventing the misuse of butane/propane - ████████ as above.
There is no age restriction on the purchase of aerosol ████████ or other products containing butane/propane as the propellant, ████████ yet their misuse is as equally dangerous.
An age restriction on such products would also likely heighten parental awareness of the dangers of such products.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Aerosol Manufacturers' Association; that does not assign responsibility.
PFD Monitor interpretation Failure to control toxic social media algorithms
Wider context from the report “3. Social media content and access
The posting of challenges such as those listed above, and no doubt others, on social media platforms will continue to take the lives of young, impressionable and/or vulnerable children/teenagers unless the platform providers take responsibility fortheir content and/or toxic algorithms either voluntarily or through Government action. The former seems unlikely.
Further the age restriction of 13 years for most social media platforms appears to have been determined in relation to data protection laws rather than of the nature of the content to which they will be exposed, again via any toxic algorithms or any searches they may make.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Aerosol Manufacturers' Association; that does not assign responsibility.
PFD Monitor interpretation Age restrictions for social media platforms failing to account for hazardous content exposure
Wider context from the report “3. Social media content and access
The posting of challenges such as those listed above, and no doubt others, on social media platforms will continue to take the lives of young, impressionable and/or vulnerable children/teenagers unless the platform providers take responsibility fortheir content and/or toxic algorithms either voluntarily or through Government action. The former seems unlikely.
Further the age restriction of 13 years for most social media platforms appears to have been determined in relation to data protection laws rather than of the nature of the content to which they will be exposed , again via any toxic algorithms or any searches they may make.
” 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 Write to social media companies to raise awareness of aerosol misuse and encourage removal of dangerous content.
Verbatim wording from the response “We note the coroner's reference to TikTok challenges. BAMA will write to social media companies to raise awareness of this problem and to encourage them to remove dangerous content. BAMA would also like to offer any assistance it can to UK regulators to help them combat the posting of this kind of material.” Source location Response from British Aerosol Manufacturers Association
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 Promote existing and updated caution labels and encourage aerosol marketers to adopt them across products placed on the UK market.
Verbatim wording from the response “BAMA believes that providing information and education on ████████ safety is essential and is committed to ensuring that aerosol marketers provide prominent caution marks on pack, which we believe would be more effective than imposing age restrictions on the sale of ████████. Since the late 1990s, BAMA has asked those placing aerosols on the UK market to add a voluntary caution mark alongside the product information, in addition to the legally required text, that reads “Solvent Abuse Can Kill Instantly” (SACKI).” Source location Response from British Aerosol Manufacturers Association
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 Developed and updated guidance for a prominent inhalation caution mark, including revised wording, placement and visibility specifications.
Verbatim wording from the response “Earlier this year, following work with Re-Solv, academia, and consumers on the changing use of language, BAMA updated its advice. It proposed an alternative mark that reads: “Intentional misuse can kill instantly. Do not deliberately inhale” along with suggested wording for an additional cautionary statement. There is also a recommendation regarding where this mark should be placed to make it more prominent to users. More details can be found below or on the BAMA website.” Source location Response from British Aerosol Manufacturers Association
Open published response
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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 Improved on-pack labelling and point-of-use information are considered sufficient, making retail age restrictions on aerosol sales unnecessary.
Verbatim wording from the response “Like other household products, aerosols are safe when used according to the manufacturer's instructions. Products are tested to ensure they comply with all relevant regulations and are labelled, as a minimum, in accordance with those regulations. We believe that the labelling of products, as detailed above, is the best way to raise awareness of the potential dangers of misusing an aerosol, including for parents and those caring for young people.” Source location Response from British Aerosol Manufacturers Association
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations