4 May 2026 Suseel RANA · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 4 Failure to recognise anxiety indicating the need for further safety planning View source Lack of clarity in DVDS Guidance about progression after intelligence checks and before disclosure decisions View source Failure to correctly understand Clare's Law applicability to previous partners View source Failure to progress Clare's Law applications through the DVDS decision-making stage and associated multi-agency referral View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Suseel RANA · 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
Suseel RANA, who had mental health conditions and was experiencing anxiety and fear linked to domestic abuse, died by suicide after ingesting an excess of a substance. Concerns included the failure to progress her Clare’s Law application, a misunderstanding about its use for a previous partner, and the failure to recognise her anxiety as requiring further safety planning and multi-agency support.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise anxiety indicating the need for further safety planning
Wider context from the report “1) In seeking some reassurance as to her safety, the Deceased had made a Clare's Law application under the Domestic Violence Disclosure Scheme (DVDS) prior to her death; however, this was had not been progressed by Police.
2) The reason for the lack of progression of the Deceased's Clare's Law application appear to have been based on a misunderstanding by the investigating officer that Clare's law could not be used in respect of a previous partner.
3) Neither the investigating officer nor the supervising officer appeared to recognise the Deceased's level of anxiety , as indicated by her Clare's Law application, required further safety planning .
4) The lack of progression of the Deceased's Clare's Law application to the actual decision making stage meant that the steps envisaged by the DVDS Guidance, which include a referral to a multi-agency forum (as illustrated by Figure 1 on page 8 of the Guidance), were not taken. Had such steps been taken, it is likely that the Deceased would have been more supported.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in DVDS Guidance about progression after intelligence checks and before disclosure decisions
Wider context from the report “5) Whilst paragraph 76 of the DVDS Guidance states: "The police may make the decision not to progress the disclosure following the completion of intelligence checks" - it is not currently clear whether the intention of the Guidance is for Police still to proceed to the decision making stage as to whether to make any disclosure or not (which would involve the multi-agency referral referenced above) or, whether, in that situation no further steps at all are required (as occurred in respect of the Deceased's application).
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly understand Clare's Law applicability to previous partners
Wider context from the report “1) In seeking some reassurance as to her safety, the Deceased had made a Clare's Law application under the Domestic Violence Disclosure Scheme (DVDS) prior to her death; however, this was had not been progressed by Police.
2) The reason for the lack of progression of the Deceased's Clare's Law application appear to have been based on a misunderstanding by the investigating officer that Clare's law could not be used in respect of a previous partner .
3) Neither the investigating officer nor the supervising officer appeared to recognise the Deceased's level of anxiety, as indicated by her Clare's Law application, required further safety planning.
4) The lack of progression of the Deceased's Clare's Law application to the actual decision making stage meant that the steps envisaged by the DVDS Guidance, which include a referral to a multi-agency forum (as illustrated by Figure 1 on page 8 of the Guidance), were not taken. Had such steps been taken, it is likely that the Deceased would have been more supported.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to progress Clare's Law applications through the DVDS decision-making stage and associated multi-agency referral
Wider context from the report “1) In seeking some reassurance as to her safety, the Deceased had made a Clare's Law application under the Domestic Violence Disclosure Scheme (DVDS) prior to her death; however, this was had not been progressed by Police .
2) The reason for the lack of progression of the Deceased's Clare's Law application appear to have been based on a misunderstanding by the investigating officer that Clare's law could not be used in respect of a previous partner.
3) Neither the investigating officer nor the supervising officer appeared to recognise the Deceased's level of anxiety, as indicated by her Clare's Law application, required further safety planning.
4) The lack of progression of the Deceased's Clare's Law application to the actual decision making stage meant that the steps envisaged by the DVDS Guidance, which include a referral to a multi-agency forum (as illustrated by Figure 1 on page 8 of the Guidance), were not taken . Had such steps been taken, it is likely that the Deceased would have been more supported.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with national safeguarding and police-conduct bodies to create a clearer, more consistent DVDS implementation framework, incorporating the issues raised.
Verbatim wording from the response “I am aware that there are issues and inconsistencies in the way that the DVDS is currently being implemented across forces in England and Wales, and that more needs to be done to make sure the current scheme is working well for victims. In the VAWG Strategy, the Home Office committed to working closely with the National Centre for VAWG and Public Protection and the Independent Office for Police Conduct to create a clearer, more consistent framework for police and other agencies to improve implementation of the DVDS.” Source location Response from 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 Ongoing safety planning for all DVDS cases should provide appropriate safeguarding support regardless of whether an application reaches decision-making.
Verbatim wording from the response “The DVDS statutory guidance indicates that it is best practice for police to refer cases to a multi-agency forum to inform disclosure decisions and advise on safeguarding measures, and that high risk applications should always be referred. However, such referrals are not mandatory and do not happen in every case. Nevertheless, the guidance recognises that in making a request, a person is often registering concerns about possible risks to their own safety. The guidance is also clear that safety planning should be undertaken for all” Source location Response from 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 Multi-agency forum referrals are not mandatory for every DVDS case, although high-risk applications should always be referred.
Verbatim wording from the response “The DVDS statutory guidance indicates that it is best practice for police to refer cases to a multi-agency forum to inform disclosure decisions and advise on safeguarding measures, and that high risk applications should always be referred. However, such referrals are not mandatory and do not happen in every case. Nevertheless, the guidance recognises that in making a request, a person is often registering concerns about possible risks to their own safety. The guidance is also clear that safety planning should be undertaken for all” Source location Response from 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 Bedfordshire Police’s Chief Constable is responsible for addressing concerns about officers’ handling of the DVDS application.
Verbatim wording from the response “At points 10(2) and 10(3) in your report you raise concerns around the way Bedfordshire Police officers handled Ms Rana’s DVDS application. I am unfortunately unable to comment on or intervene in individual cases or police investigations. This is because the police are independent of Government. However, I see that you have also shared your report with the Chief Constable for Bedfordshire Police, who I hope will be able to address these points.” Source location Response from 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 The Home Office cannot comment on or intervene in individual police cases because police forces are independent of Government.
Verbatim wording from the response “At points 10(2) and 10(3) in your report you raise concerns around the way Bedfordshire Police officers handled Ms Rana’s DVDS application. I am unfortunately unable to comment on or intervene in individual cases or police investigations. This is because the police are independent of Government. However, I see that you have also shared your report with the Chief Constable for Bedfordshire Police, who I hope will be able to address these points.” Source location Response from Home Office
Open published response
1 May 2026 Natasha Hill · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 7 Limited national dissemination of local safeguarding protocols View source Failure to formally review safeguarding, domestic violence or controlling or coercive behaviour risks affecting teenagers approaching 18 View source Lack of consistent criteria and central guidance for safeguarding offender management functions View source Lack of specific protection for young people against adults creating safeguarding risks View source Lack of one single national policy for policing and child sexual exploitation View source Lack of guidance on missing persons, runaways and return-to-home interviews View source Lack of a young person's team covering transition from under-18 services to adult safeguarding teams View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Natasha Hill · 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
Natasha Hill, who had been in care and was experiencing grooming, exploitation, self-harm, substance misuse and domestic violence, was pronounced dead at her abuser’s home in the early hours of 15 April 2018. The jury concluded that she was unlawfully killed by her abuser. The report raised concerns about safeguarding during the transition to adulthood, protection from exploitation and domestic abuse, and coordination of relevant policing and safeguarding policies.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Limited national dissemination of local safeguarding protocols
Wider context from the report “• To consider the wider dissemination of existing local protocols nationally , for example the London Exploitation Protocol.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to formally review safeguarding, domestic violence or controlling or coercive behaviour risks affecting teenagers approaching 18
Wider context from the report “• Anyone requiring/needing/suffering
o Safeguarding
o Domestic violence
o Controlling/ coercive behaviour
And incurring the consequential risks, as a teenager approaching 18 should be formally reviewed by an adult safeguarding team ad the independent reviewing officer .
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent criteria and central guidance for safeguarding offender management functions
Wider context from the report “• Re safeguarding offender management, the use of VOO's and the creation of POETs/ DAPST and RMUs: consideration should be given to the creation of one set of criteria with one name whose role it is to cover and create a central guidance .
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of specific protection for young people against adults creating safeguarding risks
Wider context from the report “• Thought should be given to the creation of a young person's protection by way of creation of an extension to the CAWN for the young person, against the adult creating that safeguarding risk e.g. young person's abuse warning notice.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of one single national policy for policing and child sexual exploitation
Wider context from the report “• The creation of one single national policy for policing and child sexual exploitation following the groundwork laid down by Operation Hydrant and local Forces.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on missing persons, runaways and return-to-home interviews
Wider context from the report “• The provision of guidance in respect of missing persons/ runaways and the return to home interviews to assist the actions of the police and local councils.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of a young person's team covering transition from under-18 services to adult safeguarding teams
Wider context from the report “• Thought should be given to creating a young person's team covering the transition from under 18 (MACE) to adult safeguarding teams e.g. For the period 18-22 .
” 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 Develop updated national guidance on VAWG protection orders, offender management, breach response and escalation pathways.
Verbatim wording from the response “While Protective Order Enforcement Teams (POETs), Domestic Abuse Problem Solving Teams (DAPSTs) and Risk Management Units (RMUs) are all distinct operational teams within policing and Violent Offender Orders (VOOs) are an important tool, we recognise that they should operate as part of a coherent system. The NCVPP helps bring together learning, guidance and best practice to improve the consistency and quality of the policing response to VAWG and public protection harms. As part of this, the NCVPP is taking forward work in a number of areas linked to risk assessment, offender management, safeguarding and protection orders including:” Source location Response from 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 Keep the child-exploitation disruption framework under review to support coordinated safeguarding and information sharing.
Verbatim wording from the response “in the Home Office’s Child Exploitation Disruption Toolkit [See more here: https://www.gov.uk/government/publications/child-exploitation-disruption-toolkit].” Source location Response from 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 Develop a consistent, victim-centred national policing response to child sexual exploitation.
Verbatim wording from the response “Matter of concern 4
The creation of one single national policy for policing and child sexual exploitation following the groundwork laid down by Operation Hydrant and local Forces.” Source location Response from Home Office
Open published response
24 Mar 2026 Robert Joseph DAY · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 1 Absence of national guidance for frontline emergency crews dealing with time-critical mental health situations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Robert Joseph DAY · 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
Robert Day died on 15 January 2025 after taking a significant overdose of prescription medication and refusing treatment after an ambulance and police response. The principal concern was the absence of national guidance for frontline emergency services dealing with complex, time-critical situations involving mental health concerns, which the report said risks the lives of others.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Absence of national guidance for frontline emergency crews dealing with time-critical mental health situations
Wider context from the report “The fundamental issue was considered to be 'what can the frontline crew actually do' in such complex situations. I heard evidence that, sadly, Robert's situation is unlikely to have been novel but that there is an absence of national guidance to frontline emergency services in dealing with the complexities of cases such as Robert's .
I acknowledge the complex interplay between the various agencies and services involved, but highlight to you my concern that the absence of any national guidance / advice to frontline emergency crews risks the lives of others who are found to be at time critical risk as a result of underlying mental health concerns .
” Open source report
10 Feb 2026 Samuel John DICKINSON · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 3 Failure to require General Practitioner practices to record firearms licence holdings in medical records View source Failure to require General Practitioner practices to report relevant health issues to firearms licence units View source Lack of a self-reporting requirement for firearms certificate holders to report relevant illness or mental health conditions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Samuel John DICKINSON · 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 John DICKINSON, a 39-year-old farmer who held firearms and shotgun licences, was found on 15 September 2025 with a shotgun wound to the head in an outbuilding at the farm where he lived. The inquest concluded that his death was suicide, with the medical cause recorded as severe head injury. Concerns were raised about gaps in firearms legislation and General Practitioner recording and reporting obligations relating to licence holders’ illnesses or mental health conditions.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to require General Practitioner practices to record firearms licence holdings in medical records
Wider context from the report “1. During the course of evidence it was reflected that Firearms Legislation relating to the holding of a shotgun or firearms licence (or both) contains no provision that a person holding a certificate must self report any illness or mental health condition which may give rise to a change in circumstances from the time when a grant of licence has been made, differing from obligations for example on a person holding a driving licence to do so.
2. Further it was stated that there is no obligation or provision requiring a General Practitioner practice to:
a. Clearly record the holding of a licence on medical records when advised of the grant, in order to assist with flagging any relevant issues that may need reporting (such as conditions listed on an initial firearms/shotgun application form or renewal)
b. Requiring the reporting of such issues on a reasonable basis to a firearms licence unit of a local police force
3. The above were described as ‘gaps’ in the legislation which may give rise to the risk of future 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to require General Practitioner practices to report relevant health issues to firearms licence units
Wider context from the report “1. During the course of evidence it was reflected that Firearms Legislation relating to the holding of a shotgun or firearms licence (or both) contains no provision that a person holding a certificate must self report any illness or mental health condition which may give rise to a change in circumstances from the time when a grant of licence has been made, differing from obligations for example on a person holding a driving licence to do so.
2. Further it was stated that there is no obligation or provision requiring a General Practitioner practice to:
a. Clearly record the holding of a licence on medical records when advised of the grant, in order to assist with flagging any relevant issues that may need reporting (such as conditions listed on an initial firearms/shotgun application form or renewal)
b. Requiring the reporting of such issues on a reasonable basis to a firearms licence unit of a local police force
3. The above were described as ‘gaps’ in the legislation which may give rise to the risk of future 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of a self-reporting requirement for firearms certificate holders to report relevant illness or mental health conditions
Wider context from the report “1. During the course of evidence it was reflected that Firearms Legislation relating to the holding of a shotgun or firearms licence (or both) contains no provision that a person holding a certificate must self report any illness or mental health condition which may give rise to a change in circumstances from the time when a grant of licence has been made , differing from obligations for example on a person holding a driving licence to do so.
2. Further it was stated that there is no obligation or provision requiring a General Practitioner practice to:
a. Clearly record the holding of a licence on medical records when advised of the grant, in order to assist with flagging any relevant issues that may need reporting (such as conditions listed on an initial firearms/shotgun application form or renewal)
b. Requiring the reporting of such issues on a reasonable basis to a firearms licence unit of a local police force
3. The above were described as ‘gaps’ in the legislation which may give rise to the risk of future death.
” 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 Implement a digital firearms marker across GP surgeries to alert doctors about relevant conditions and prompt police notifications.
Verbatim wording from the response “person is granted a firearm or shotgun certificate, and this remains on the system for the five years’ duration of the licence. If a certificate holder sees their GP regarding a relevant medical condition during this period, the doctor can advise the police of this, enabling the police to carry out a review as to whether the person remains suitable to have a licence.” Source location Response from 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 Review whether and how to mandate the digital firearms marker in future.
Verbatim wording from the response “A new digital version of the firearms marker was introduced to all GP surgeries in England in May 2023. The digital firearms marker automatically alerts the doctor if a patient is seen regarding a relevant medical condition and reminds the GP to advise the police. This improves the safety of the system and helps to ensure that the firearms marker is not missed by GPs. The data we have on the use of the digital marker shows that it is now being applied by GPs. In 2024-25, over 98,000 digital markers were applied by GPs to the medical record of those granted or renewed a firearm or shotgun certificate and there were over 1,100 cases in which the GP notified the police of a medical concern about a licence holder, following a review prompted by the digital firearms marker.” Source location Response from 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 Introduce a licensing condition requiring holders to report new relevant medical conditions or significant worsening of existing conditions to police.
Verbatim wording from the response “We recognise this as a potential area for strengthening. We are therefore shortly bringing forward a new Statutory Instrument to add a new condition to firearms and shotgun licences to require the holder to inform the police if they begin to suffer from a new relevant medical condition, or if an existing condition significantly worsens, during the lifetime of the licence. This will enable the police to assess whether the change affects the person’s suitability to continue to possess the firearm or shotgun. At the same time, we will also be introducing a new licensing condition to require the licence holder to inform the police if they consult a third-party medical practitioner who is not their GP, to ensure that the police have a full picture of the licence holder’s health.” Source location Response from Home Office
Open published response
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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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. The report was sent to Home Office; that does not assign responsibility.
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 .
” 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 Home Office; that does not assign responsibility.
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.
” Open source report
Concerns raised 3 Failure to communicate dynamic risk assessments to the control centre during pursuits View source Single-manning of pursuit crews requiring one officer to undertake all pursuit tasks View source Failure to identify vital risk information during pursuits because of competing driving tasks View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alexander Rhys Lewis · 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
Alexander Rhys Lewis, a motorcyclist, died from chest injuries following a road traffic collision while being pursued by police. The report raises concerns that a pursuing officer had to undertake multiple tasks alone, limiting communication of dynamic risk assessments and causing vital information about risks, including a red-light contravention, to be missed. Evidence also indicated that double-manning the pursuit crew would be safer, although this would reduce the number of available trained units.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate dynamic risk assessments to the control centre during pursuits
Wider context from the report “During the course of the inquest evidence was heard regarding the circumstances that the pursuit occurred and the events that unfolded. One such instance was that the pursuing police officer did not observe Alex contravening a red light due to having to control his vehicle as well as negotiating the other traffic and he would have had to be looking around to do this, whereas the dashcam fitted to the car that picked up the contravention of the red light continued to point straight ahead. The impact of this was that had he seen it, it may have raised the dynamic risk assessment to high and may have caused him to stand the pursuit down. The pursuing driver also stated that given the driving responsibilities there was no opportunity to communicate a dynamic risk assessment to the control centre , although he would have been undertaking a dynamic risk assessment throughout.
The evidence of the officer in charge of driver training confirmed the evidence of the pursuing officer in that the pursuing officer would have to do a number of things including declaring a pursuit and negotiating the traffic. In his words “...there would be a lot going on in the car...”. He stated that the pursuing officer would be on their own in the car and as such have to undertake all the tasks involved in a pursuit themselves, and acknowledged that it would be safer for the crew to be double manned so the tasks can be shared, although you are then halving the number of TPAC trained units available to assist.
I am concerned that in pursuit situations, pursuit officers are required to undertake a significant number of tasks on their own, and the decisions they take as a result of undertaking those tasks can have an impact on their safety, the subject vehicle’s safety as well as the safety of other road users and the general public.
1. There was no opportunity for the pursuing driver to communicate a dynamic risk assessment to the control centre, to assist the control centre in making a decision to authorise or stand down the pursuit . the control centre indicated that such information would go towards authorising the pursuit as opposed to standing it down in the present case
2. The number of tasks having to be undertaken by the pursuing driver meant that vital information as to the risks involved in continuing the pursuit were missed, in the present case that being a contravention of a red light
3. The officer in charge of driver training confirmed that from a safety perspective, it would be safer to have the crew in a pursuit situation “double manned”.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Single-manning of pursuit crews requiring one officer to undertake all pursuit tasks
Wider context from the report “During the course of the inquest evidence was heard regarding the circumstances that the pursuit occurred and the events that unfolded. One such instance was that the pursuing police officer did not observe Alex contravening a red light due to having to control his vehicle as well as negotiating the other traffic and he would have had to be looking around to do this, whereas the dashcam fitted to the car that picked up the contravention of the red light continued to point straight ahead. The impact of this was that had he seen it, it may have raised the dynamic risk assessment to high and may have caused him to stand the pursuit down. The pursuing driver also stated that given the driving responsibilities there was no opportunity to communicate a dynamic risk assessment to the control centre, although he would have been undertaking a dynamic risk assessment throughout.
The evidence of the officer in charge of driver training confirmed the evidence of the pursuing officer in that the pursuing officer would have to do a number of things including declaring a pursuit and negotiating the traffic. In his words “...there would be a lot going on in the car...”. He stated that the pursuing officer would be on their own in the car and as such have to undertake all the tasks involved in a pursuit themselves , and acknowledged that it would be safer for the crew to be double manned so the tasks can be shared, although you are then halving the number of TPAC trained units available to assist.
I am concerned that in pursuit situations, pursuit officers are required to undertake a significant number of tasks on their own, and the decisions they take as a result of undertaking those tasks can have an impact on their safety, the subject vehicle’s safety as well as the safety of other road users and the general public.
1. There was no opportunity for the pursuing driver to communicate a dynamic risk assessment to the control centre, to assist the control centre in making a decision to authorise or stand down the pursuit. the control centre indicated that such information would go towards authorising the pursuit as opposed to standing it down in the present case
2. The number of tasks having to be undertaken by the pursuing driver meant that vital information as to the risks involved in continuing the pursuit were missed, in the present case that being a contravention of a red light
3. The officer in charge of driver training confirmed that from a safety perspective, it would be safer to have the crew in a pursuit situation “double manned” .
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to identify vital risk information during pursuits because of competing driving tasks
Wider context from the report “During the course of the inquest evidence was heard regarding the circumstances that the pursuit occurred and the events that unfolded. One such instance was that the pursuing police officer did not observe Alex contravening a red light due to having to control his vehicle as well as negotiating the other traffic and he would have had to be looking around to do this, whereas the dashcam fitted to the car that picked up the contravention of the red light continued to point straight ahead. The impact of this was that had he seen it, it may have raised the dynamic risk assessment to high and may have caused him to stand the pursuit down. The pursuing driver also stated that given the driving responsibilities there was no opportunity to communicate a dynamic risk assessment to the control centre, although he would have been undertaking a dynamic risk assessment throughout.
The evidence of the officer in charge of driver training confirmed the evidence of the pursuing officer in that the pursuing officer would have to do a number of things including declaring a pursuit and negotiating the traffic. In his words “...there would be a lot going on in the car...”. He stated that the pursuing officer would be on their own in the car and as such have to undertake all the tasks involved in a pursuit themselves, and acknowledged that it would be safer for the crew to be double manned so the tasks can be shared, although you are then halving the number of TPAC trained units available to assist.
I am concerned that in pursuit situations, pursuit officers are required to undertake a significant number of tasks on their own, and the decisions they take as a result of undertaking those tasks can have an impact on their safety, the subject vehicle’s safety as well as the safety of other road users and the general public.
1. There was no opportunity for the pursuing driver to communicate a dynamic risk assessment to the control centre, to assist the control centre in making a decision to authorise or stand down the pursuit. the control centre indicated that such information would go towards authorising the pursuit as opposed to standing it down in the present case
2. The number of tasks having to be undertaken by the pursuing driver meant that vital information as to the risks involved in continuing the pursuit were missed , in the present case that being a contravention of a red light
3. The officer in charge of driver training confirmed that from a safety perspective, it would be safer to have the crew in a pursuit situation “double manned”.
” 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 Chief Constables are responsible for operational crewing decisions and deployment of available police resources, based on local problems and demands.
Verbatim wording from the response “Crewing
Decisions on crewing are operational matters and at the discretion and judgement of Chief Constables who determine how to deploy available resources to deal with issues for which the force is responsible, considering specific local problems and demands.” Source location Response from Minister of State for Policing and Crime
Open published response
17 Oct 2025 OWEN AUSTIN DONNELLY · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 3 Failure to criminalise possession of items enabling weapon construction View source Unrestricted internet access to information enabling construction of weapons View source Proliferation of unlicensed weapons View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
OWEN AUSTIN DONNELLY · 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
OWEN AUSTIN DONNELLY was discovered collapsed and unresponsive in the garden of his residence on 16 February 2025, with a self-inflicted head wound, and was verified dead by attending paramedics. The inquest concluded suicide. Concerns included the ability to research, access, download and use material widely available on the internet, the fact that possession of material enabling construction of such a weapon was not then a criminal offence, and the risk posed while proposed legislation remained under consideration.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to criminalise possession of items enabling weapon construction
Wider context from the report “1. The deceased was able research, access, download and then to make use of ████████ widely available on the internet, primarily from the United States, ████████
2. The possession of ████████ that can enable an individual to construct a ████████ is not currently a criminal offence .
3. I heard evidence from a ████████ expert that there is an alarming proliferation of ████████ weapons within England and Wales, ████████ ████████ that are unlicensed and therefore increasingly available for criminal or nefarious purposes.
4. A Bill criminalising the possession of such ████████ is awaiting a second reading before Parliament. Until such time proposed legislation is enacted , there remains a real and immediate risk that individuals may access the internet ████████ ████████
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Unrestricted internet access to information enabling construction of weapons
Wider context from the report “1. The deceased was able research, access, download and then to make use of ████████ widely available on the internet , primarily from the United States, ████████
2. The possession of ████████ that can enable an individual to construct a ████████ is not currently a criminal offence.
3. I heard evidence from a ████████ expert that there is an alarming proliferation of ████████ weapons within England and Wales, ████████ ████████ that are unlicensed and therefore increasingly available for criminal or nefarious purposes.
4. A Bill criminalising the possession of such ████████ is awaiting a second reading before Parliament. Until such time proposed legislation is enacted, there remains a real and immediate risk that individuals may access the internet ████████ ████████
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Proliferation of unlicensed weapons
Wider context from the report “1. The deceased was able research, access, download and then to make use of ████████ widely available on the internet, primarily from the United States, ████████
2. The possession of ████████ that can enable an individual to construct a ████████ is not currently a criminal offence.
3. I heard evidence from a ████████ expert that there is an alarming proliferation of ████████ weapons within England and Wales , ████████ ████████ that are unlicensed and therefore increasingly available for criminal or nefarious purposes .
4. A Bill criminalising the possession of such ████████ is awaiting a second reading before Parliament. Until such time proposed legislation is enacted, there remains a real and immediate risk that individuals may access the internet ████████ ████████
” 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 Enact legislation criminalising the import, manufacture, adaptation, supply, offering, and possession of specified items.
Verbatim wording from the response “I am able to confirm that all of your recommendations should be addressed before the New Year. Turning to your report, the first of your concerns was that ████████ are readily accessible on the internet to enable the construction of ████████. Your second concern was that the possession of such ████████ is not currently a criminal offence. These two concerns will be addressed by the Border Security, Asylum and Immigration Bill, which is currently completing its passage through the House of Lords. Once enacted, the Bill will make it a criminal offence to import, make, adapt, supply, offer to supply and ████████ ████████ that can be used ████████.” Source location Response from 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 Existing legal controls and penalties are considered sufficient to address the concern about proliferation, regardless of the manufacturing method.
Verbatim wording from the response “You were also concerned about the proliferation of ████████ It is already the case that a ████████. For the purposes of the ████████, the method of manufacture is immaterial.” Source location Response from Home Office
Open published response
2 Oct 2025 Georgia Jay Barter · Prevention of Future Deaths report East London
View report summary
Concerns raised 1 Limited access for frontline police officers to the Police National Database for cross-border domestic abuse history checks View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Georgia Jay Barter · 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
Georgia Jay Barter died on 26 April 2020 after an act of self-harm following an assault by her partner during a long-term abusive relationship. The principal concern was that frontline police officers may have limited access to the Police National Database, making it difficult to identify reported domestic abuse linked to individuals across different police-force areas.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Limited access for frontline police officers to the Police National Database for cross-border domestic abuse history checks
Wider context from the report “The concern I have is that there is difficulty for front line officers in police forces across the country to easily access the police national database to check on individuals who are suspected of domestic abuse. They are unable to easily identify if the individual has a history of reported domestic abuse in areas outside that forces' borders . This would allow police to be more proactive in their dealings with victims of domestic violence. I understand that some forces have implemented changes to facilitate better exchange of information and access to PND. However, I am concerned that there may be forces which continue to have limited access for front line police officers to the PND . This is on a background of rising numbers of domestic violence cases in this country. It accounts for 20% of all crime in Essex.
” 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 Stabilise the Police National Database by addressing legacy challenges before wider police-intelligence transformation.
Verbatim wording from the response “The PND went live in 2011 and receives regular technical upgrades. The Home Office has a current programme designed to alleviate some of the current legacy challenges and to stabilise this Critical National Infrastructure application prior to any wider transformation of police intelligence.” Source location Response from Home Office
Open published response
23 Sep 2025 Leonardo Cardoso Machado · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Lack of oversight of the rental of food delivery licences to children under 18 View source Failure to protect children from vulnerable lone food-delivery work at night and at private homes View source Failure to protect child food-delivery workers from road traffic collision risks View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Leonardo Cardoso Machado · 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
Leonardo Cardoso Machado, aged 17, died on 16 April 2023 after losing control of a motorcycle and colliding with metal railings while fleeing a police traffic stop. Concerns included limited oversight of rented food-delivery licences for children under 18, and the vulnerability and road-traffic risks associated with children working alone at night on motorised vehicles.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of oversight of the rental of food delivery licences to children under 18
Wider context from the report “2. I have concerns with regard to the following:
i. There appears to be no or limited oversight of the practice of “renting” a food delivery licence to children under 18 years of age , which I regard is a national issue;
ii. As a consequence, children are working in the food delivery economy, which involves lone working at night, with deliveries being made to the home addresses of private individuals, placing the children in a vulnerable position;
iii. That placing children in a lone working environment at night and on the roads on electric or motorised scooters, mopeds or motorcycles also increases the risks of them coming to harm through a road traffic collision, leading to a risk of 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to protect children from vulnerable lone food-delivery work at night and at private homes
Wider context from the report “2. I have concerns with regard to the following:
i. There appears to be no or limited oversight of the practice of “renting” a food delivery licence to children under 18 years of age, which I regard is a national issue;
ii. As a consequence, children are working in the food delivery economy, which involves lone working at night, with deliveries being made to the home addresses of private individuals, placing the children in a vulnerable position ;
iii. That placing children in a lone working environment at night and on the roads on electric or motorised scooters, mopeds or motorcycles also increases the risks of them coming to harm through a road traffic collision, leading to a risk of 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to protect child food-delivery workers from road traffic collision risks
Wider context from the report “2. I have concerns with regard to the following:
i. There appears to be no or limited oversight of the practice of “renting” a food delivery licence to children under 18 years of age, which I regard is a national issue;
ii. As a consequence, children are working in the food delivery economy, which involves lone working at night, with deliveries being made to the home addresses of private individuals, placing the children in a vulnerable position;
iii. That placing children in a lone working environment at night and on the roads on electric or motorised scooters, mopeds or motorcycles also increases the risks of them coming to harm through a road traffic collision, leading to a risk of death .
” Open source report
19 Sep 2025 Rebekah Arter · Prevention of Future Deaths report South London
View report summary
Concerns raised 2 Failure to consider domestic abuse risk at police dismissal View source Failure of investigations to identify victims of domestic abuse and coercive control View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rebekah Arter · 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
Rebekah Arter, aged 47, died in a hotel room in Barbados on 28 June 2024 in circumstances involving likely intoxication; the medical cause of death was unascertained and the inquest conclusion was open. The principal concern was that missed opportunities by the IOPC and Metropolitan Police Service may have prevented identification of Rebekah as a victim of domestic abuse and coercive control, and prevented protective action.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to consider domestic abuse risk at police dismissal
Wider context from the report “That there may have been missed opportunities for the IOPC and Metropolitan Police Service from their investigations to identify that Rebekah was a victim of domestic abuse and coercive control, which would have enabled her to be protected. This is illustrated by these facts:
• That Rebekah had met her husband initially as a victim of a crime.
• That police investigations uncovered a large number of women with whom he had inappropriate relationships and that he misused his police powers.
• That he was dismissed from the police for drug offences in May 2023, but the risk to Rebekah was not apparently considered at that time .
• A witness has alleged that a video was sent by him of Rebekah ████████ which the family allege was used to shame and enforce control over her, allegedly in 2023.
• A history of her having unexplained repeated bruises and injuries was available in 2024 to anyone who enquired about the risk of domestic abuse.
• ████████
• That in retrospect it is recognised by a Detective Chief Inspector that he was an exceptionally persistent and damaging offender against women, but no charges in relation to that had ever been brought.
The coroner did not accept submissions from the family that the inquest engaged Article 2 of the European Convention on Human Rights and ruled that details of the seven years of conduct investigations were beyond the scope of the inquest.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of investigations to identify victims of domestic abuse and coercive control
Wider context from the report “That there may have been missed opportunities for the IOPC and Metropolitan Police Service from their investigations to identify that Rebekah was a victim of domestic abuse and coercive control , which would have enabled her to be protected. This is illustrated by these facts:
• That Rebekah had met her husband initially as a victim of a crime.
• That police investigations uncovered a large number of women with whom he had inappropriate relationships and that he misused his police powers.
• That he was dismissed from the police for drug offences in May 2023, but the risk to Rebekah was not apparently considered at that time.
• A witness has alleged that a video was sent by him of Rebekah ████████ which the family allege was used to shame and enforce control over her, allegedly in 2023.
• A history of her having unexplained repeated bruises and injuries was available in 2024 to anyone who enquired about the risk of domestic abuse .
• ████████
• That in retrospect it is recognised by a Detective Chief Inspector that he was an exceptionally persistent and damaging offender against women, but no charges in relation to that had ever been brought.
The coroner did not accept submissions from the family that the inquest engaged Article 2 of the European Convention on Human Rights and ruled that details of the seven years of conduct investigations were beyond the scope of the inquest.
” 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 Provide £13.1 million to establish a National Centre for VAWG and Public Protection.
Verbatim wording from the response “I am very sorry to hear about the experiences Rebekah went through as a victim of domestic and sexual abuse, as noted in your report. I recognise the devastating impact these awful crimes can have on their victims. I would like to reassure you that this Government is committed to tackling all forms of violence against women and girls (VAWG), including domestic and sexual abuse. We have set out an unprecedented mission to halve VAWG in a decade. Improving policing practice is a key part of this, and we have provided £13.1m this year to establish a new National Centre for VAWG and Public Protection which will help drive consistency nationally, including through the development of specialist training on VAWG to ensure that officers are well equipped to manage offences and provide consistent support to victims.” Source location Response from Home Office
Open published response
Concerns raised 1 Insufficient resources for timely allocation of police officers to priority cases View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Khalif Mohammed · 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
Khalif Mohammed, who was detained in hospital under section 3 of the Mental Health Act, failed to return from unescorted leave on 6 January 2025 and was found deceased at his flat the following day. The medical cause of death was recorded as haemopericardium and haemothorax due to a stab wound, and the inquest conclusion was suicide. The report raised concerns about insufficient police resources and a significant delay in allocating officers to his priority missing-person case.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Insufficient resources for timely allocation of police officers to priority cases
Wider context from the report “1. The inquest heard that West Midlands Police had insufficient resources to allocate police officers to deal with Khalif's case on 06/01/25 which was classed as a priority case with expected allocation of resources within an hour . As a result, there was a significant delay in officers being allocated to the case . Whilst it could not be shown that this affected the outcome for Khalif, there is a risk of future deaths if the available resources are not sufficient to deal with the large numbers of cases received each day and in my view, action should be taken.
” 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 Provide £200 million nationally to kickstart recruitment of 13,000 additional neighbourhood-policing officers, PCSOs and special constables.
Verbatim wording from the response “In addition to the funding announced at the settlement, we are providing £120 million of in-year funding to support forces in meeting the cost of the 2025-26 pay award. The settlement also includes funding to support the costs of the 2024-25 pay award, the increase in the employer national insurance contributions, funding for officer maintenance and an additional £200 million nationally to kickstart the first phase of recruiting 13,000 additional police officers, PCSOs and special constables into neighbourhood policing roles.” Source location Response from 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 Provide increased police funding for 2025–26 settlements, pay awards, employer contributions and officer maintenance.
Verbatim wording from the response “The Chancellor has announced a real terms increase in police spending power over the next three years. For this financial year, the 2025-26 final police funding settlement provides funding of up to £19.6 billion for the policing system in England and Wales. This is an overall increase of up to £1.2 billion when compared to the 2024-25 settlement. West Midlands Police will receive up to £846.9 million in funding in 2025-26, an increase of up to £56.5 million (7.2%) when compared to the 2024-25 police settlement.” Source location Response from 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 Set expectations for forces to reduce inefficiencies and maximise productivity through the Police Efficiency and Collaboration Programme.
Verbatim wording from the response “It is the responsibility of locally elected Police and Crime Commissioners, Mayors and Chief Constables to take decisions around their resourcing according to local needs. However, the Government recognises the challenges faced by police chiefs in prioritising finite resources and is committed to ensure that police forces can effectively tackle a wide range of public safety issues. We have set out our expectation to forces to reduce inefficiencies and maximise productivity driven through a new Police Efficiency and Collaboration Programme. This will free up cashable savings and officer time to reinvest in frontline activities. The Government will continue to engage with forces to ensure that” Source location Response from 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 Local Police and Crime Commissioners, Mayors and Chief Constables are responsible for resourcing decisions according to local needs.
Verbatim wording from the response “It is the responsibility of locally elected Police and Crime Commissioners, Mayors and Chief Constables to take decisions around their resourcing according to local needs. However, the Government recognises the challenges faced by police chiefs in prioritising finite resources and is committed to ensure that police forces can effectively tackle a wide range of public safety issues. We have set out our expectation to forces to reduce inefficiencies and maximise productivity driven through a new Police Efficiency and Collaboration Programme. This will free up cashable savings and officer time to reinvest in frontline activities. The Government will continue to engage with forces to ensure that” Source location Response from Home Office
Open published response
19 Aug 2025 Gemma May Weeks · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Lack of understanding of the health consequences of chronic ketamine use outside professional circles View source Lack of understanding of ketamine risks among the age group most at risk of starting use View source Lack of public understanding of the dangers of acute and chronic ketamine use View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gemma May Weeks · 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
Gemma May Weeks, a long-term ketamine user, was found deceased on 26 January 2025 after consuming high levels of ketamine and another substance; the combined effects caused her death. The report raises concerns that the acute and chronic risks of ketamine, including addiction and severe bladder damage, are not well understood by the public, potential first-time users, and groups at greatest risk of starting to use it.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the health consequences of chronic ketamine use outside professional circles
Wider context from the report “2. I have concerns with regard to the following:
i. The dangers and risk associated with both acute and chronic ketamine use are not well understood by the public and potential first time users of the drug. Ketamine’s classification as a class B controlled drug may give an impression that the dangers associated with its use are reduced as compared with class A drugs.
ii. There is little understanding of the risks and dangers of ketamine use amongst the age group that appear to be at most risk of starting to use the drug.
iii. The health consequences of chronic ketamine use are well understood by those that encounter them, including drug treatment providers and those working in healthcare. Those consequences are not, however, well understood outside of those circles.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of ketamine risks among the age group most at risk of starting use
Wider context from the report “2. I have concerns with regard to the following:
i. The dangers and risk associated with both acute and chronic ketamine use are not well understood by the public and potential first time users of the drug. Ketamine’s classification as a class B controlled drug may give an impression that the dangers associated with its use are reduced as compared with class A drugs.
ii. There is little understanding of the risks and dangers of ketamine use amongst the age group that appear to be at most risk of starting to use the drug.
iii. The health consequences of chronic ketamine use are well understood by those that encounter them, including drug treatment providers and those working in healthcare. Those consequences are not, however, well understood outside of those circles.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of public understanding of the dangers of acute and chronic ketamine use
Wider context from the report “2. I have concerns with regard to the following:
i. The dangers and risk associated with both acute and chronic ketamine use are not well understood by the public and potential first time users of the drug. Ketamine’s classification as a class B controlled drug may give an impression that the dangers associated with its use are reduced as compared with class A drugs.
ii. There is little understanding of the risks and dangers of ketamine use amongst the age group that appear to be at most risk of starting to use the drug.
iii. The health consequences of chronic ketamine use are well understood by those that encounter them, including drug treatment providers and those working in healthcare. Those consequences are not, however, well understood outside of those circles.
” 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 Consider all ACMD recommendations before making decisions on ketamine’s classification under the Misuse of Drugs Act.
Verbatim wording from the response “The ACMD has been working on that assessment, including conducting a public call for evidence in August. I expect to receive the report by the end of 2025, and I will give full consideration to all its recommendations before making any decisions relating to the classification of ketamine under the MDA.” Source location Response from 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 Launch a national media campaign highlighting the harms caused by ketamine through multiple media channels.
Verbatim wording from the response “While the ACMD report will be very important, the Government is, as I have noted, very concerned about the increasing harms of ketamine and is already taking a range of measures to tackle them. As the Department of Health and Social Care sets out in its response, we will shortly be launching a national media campaign on emerging drug threats, one of whose key areas of focus will be the harms caused by ketamine. The campaign will use a range of media to ensure that the messages reach as many people as possible. This sits alongside a range of existing measures, including our work with festival organisers to ensure that the risks to those attending festivals are minimised, improving the drug treatment response, and awareness raising initiatives led by local authority public health teams.” Source location Response from 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 Departments for Education and Health and Social Care will address concerns about understanding ketamine’s dangers, including among young people.
Verbatim wording from the response “I know that you sent your report to the Secretaries of State for Education and Health and Social Care too. Ministers in those departments will be replying to your concerns about a lack of understanding of the dangers of ketamine, including among young people. I will therefore focus on your concern that ketamine’s classification as a Class B drug under the Misuse of Drugs Act 1971 (‘MDA’) may give the impression that the dangers associated with its use are lower than those of Class A drugs.” Source location Response from Home Office
Open published response
10 Jul 2025 Jairus Joshua Timothy Earl · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Lack of inter-force sharing and flagging of information about shotgun licence holders and shotgun locations View source Lack of requirements for shotgun licence holders to notify police forces of additional properties and visits to other force areas View source Lack of police access to medical information about other residents during firearm and shotgun licence applications View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jairus Joshua Timothy Earl · 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
Jairus Joshua Timothy Earl, aged 15, died by suicide on 14 April 2024 after using one of his father’s shotguns at the family’s Dorset property. The concerns relate to gaps in the regulation of shotgun licences, including the lack of requirements to notify police about additional properties, inadequate information-sharing and address flagging between police forces, and limited access to medical information about other people living at a licence holder’s property.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of inter-force sharing and flagging of information about shotgun licence holders and shotgun locations
Wider context from the report “(1) I have concerns in relation to gaps in the regulation of shotgun licences especially when a licence holder has more than one property where the guns may be used or stored. The Firearms Act 1968 (The Act) is the primary legislation that governs the possession and handling of firearms. This is supported by statutory guidance, Firearms Licensing: Statutory Guidance for Chief Officers of Police and non statutory Home Office guidance, Guide on firearms Licensing Law.
Section 2 of the Act deals with the requirement of certificate for possession of shotguns. Evidence was given at the Inquest by Acting Chief Inspector ████████ of Dorset Police who works within the Dorset Firearms and Explosive Licensing Unit and also works with the College of Policing and the national Firearms & Explosive Licencing Working Group to review and update the Home Office statutory guidance and support the national training effort in response to the Prevention of Future Deaths report from the Inquest touching upon the deaths in Keyham on 12th August 2021.
He gave evidence that the regulation for shotguns is different to the regulations for firearms which is governed by Section 1 of The Act. There seems to be a great deal of difference in the regulation of firearms and the regulation of shotguns, however both can equally cause death.
I am concerned that the lack of regulation around shotguns could lead to future deaths. For example, he explained that there is no obligation on a licence holder of a shotgun licence to notify the approving force they are moving to or visiting another property
In his written evidence to the Court, which was further expanded on orally at the Inquest, he explained:
“Under section 26B(1) of the 1968 Act, an application for the grant of a shotgun shall be made to the chief officer of police where the applicant resides, there is nothing within the firearms act to define a residence or when applicants have properties in different force areas, the non-statutory guide tells me that where an applicant has a residences in different force areas, it is for the individual to decide which force issues their certificate.
Shotgun certificates are issued by individual forces’ and will display the force crest and signature of the chief officer of the issuing force, however they are valid throughout England and Wales, and allows the holder to travel with their shotguns anywhere in the United Kingdom.
…
Shotgun certificates differ from firearm certificates in a number of ways, for firearms, possession of each and every gun must satisfy individual good reason, whereas a good reason for a shotgun is a collective term, and more relaxed, for example a request for a firearms certificate for target shooting will require that the applicant is a member of a Home Office approved club and shoots regularly, whereas a mere intention to undertake clay pigeon shooting would satisfy good reason for a shotgun certificate.
A shotgun certificate also will also authorise a person to have in their possession, purchase or acquire and unlimited number of shotguns without the need for approval in respect of individual guns, that is to say that so long as the shotguns are stored securely a person may have as many as they want.
Another nuance of the shotgun certificate is the ’72-hour rule’ that it will allow a certificate holder to borrow a shotgun for up to 72 hours without the need to have to record the shotgun on the certificate or notify the police of the transfer.
…
Section 28(2)(a) of the 1968 Act provides that a shotgun certificate is granted subject to any prescribed conditions, and no others, that is that these conditions must be applied to the certificate, but the chief officer cannot add additional conditions.
…
There is no onus on an applicant to notify another force area where they hold a certificate and have another address in that force area, this is only the case if the certificate holder changes their permanent address that this would be captured by the third condition.
There is also no obligation on a certificate holder to notify a chief officer of police when they intent to visit another force area in possession of their shotguns.
Acting Chief Inspector ████████ explained that on the Tuesday following Jairus’ death he briefed the national coordinator from the Firearms & Explosive Licencing Working Group to raise matters arising from the circumstances of Jairus’ death so there is awareness of the issues relating to second homes, however, there is no legal requirement for second homes to be declared by licence holders.
He further told the Court that in 2015, HM Inspection of Firearms Licencing recommended that forces must have a notification system on their local records to identify addresses and people where firearms are held. He explained that these systems are local rather than national and his recommendation to the Firearms & Explosive Licencing Working Group following Jairus’s death was that where an applicant declares a second home, the force where that home is located should be notified.
Dorset Police have taken action and put a system in place that when they are notified of the above, they will create a record on their system to flag the address as if that were a Dorset certificate holder, however it is not a legal requirement for forces to do this, and it is unknown if other forces nationally are doing this.
I therefore have concerns there is a lack of a system of sharing and flagging information between Police forces regarding shotgun licence holders and the location of shotguns , which could lead to future deaths.
Accordingly, emergency services may attend an address where shotguns are held without knowledge of that fact due to the lack of a marker being placed on the address . This causes a risk to all those attending unmarked addresses as they would potentially be ill prepared for what they could face which could lead to future deaths.
Additionally failing to have such markers on additional homes means that if the police are called to the address for other reasons such as a concern for welfare, they may miss the opportunity to put in place additional security measures ,or even revoke the licences , as required for the safety of the occupants at the address, and others. Evidence was heard that Dorset Police were called to Jairus’s family address in Dorset on the 28th March 2024 following a report that Jairus was missing. It was not apparent from the Police system at the time that there would be shotguns at the address. Jairus’s mental health was discussed during the report of this incident. Had the flag system been in place then, consideration could have been given to the continued possession of the shotgun in a property where Jairus could access them.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of requirements for shotgun licence holders to notify police forces of additional properties and visits to other force areas
Wider context from the report “(1) I have concerns in relation to gaps in the regulation of shotgun licences especially when a licence holder has more than one property where the guns may be used or stored. The Firearms Act 1968 (The Act) is the primary legislation that governs the possession and handling of firearms. This is supported by statutory guidance, Firearms Licensing: Statutory Guidance for Chief Officers of Police and non statutory Home Office guidance, Guide on firearms Licensing Law.
Section 2 of the Act deals with the requirement of certificate for possession of shotguns. Evidence was given at the Inquest by Acting Chief Inspector ████████ of Dorset Police who works within the Dorset Firearms and Explosive Licensing Unit and also works with the College of Policing and the national Firearms & Explosive Licencing Working Group to review and update the Home Office statutory guidance and support the national training effort in response to the Prevention of Future Deaths report from the Inquest touching upon the deaths in Keyham on 12th August 2021.
He gave evidence that the regulation for shotguns is different to the regulations for firearms which is governed by Section 1 of The Act. There seems to be a great deal of difference in the regulation of firearms and the regulation of shotguns, however both can equally cause death.
I am concerned that the lack of regulation around shotguns could lead to future deaths. For example, he explained that there is no obligation on a licence holder of a shotgun licence to notify the approving force they are moving to or visiting another property
In his written evidence to the Court, which was further expanded on orally at the Inquest, he explained:
“Under section 26B(1) of the 1968 Act, an application for the grant of a shotgun shall be made to the chief officer of police where the applicant resides, there is nothing within the firearms act to define a residence or when applicants have properties in different force areas, the non-statutory guide tells me that where an applicant has a residences in different force areas, it is for the individual to decide which force issues their certificate.
Shotgun certificates are issued by individual forces’ and will display the force crest and signature of the chief officer of the issuing force, however they are valid throughout England and Wales, and allows the holder to travel with their shotguns anywhere in the United Kingdom.
…
Shotgun certificates differ from firearm certificates in a number of ways, for firearms, possession of each and every gun must satisfy individual good reason, whereas a good reason for a shotgun is a collective term, and more relaxed, for example a request for a firearms certificate for target shooting will require that the applicant is a member of a Home Office approved club and shoots regularly, whereas a mere intention to undertake clay pigeon shooting would satisfy good reason for a shotgun certificate.
A shotgun certificate also will also authorise a person to have in their possession, purchase or acquire and unlimited number of shotguns without the need for approval in respect of individual guns, that is to say that so long as the shotguns are stored securely a person may have as many as they want.
Another nuance of the shotgun certificate is the ’72-hour rule’ that it will allow a certificate holder to borrow a shotgun for up to 72 hours without the need to have to record the shotgun on the certificate or notify the police of the transfer.
…
Section 28(2)(a) of the 1968 Act provides that a shotgun certificate is granted subject to any prescribed conditions, and no others, that is that these conditions must be applied to the certificate, but the chief officer cannot add additional conditions.
…
There is no onus on an applicant to notify another force area where they hold a certificate and have another address in that force area , this is only the case if the certificate holder changes their permanent address that this would be captured by the third condition.
There is also no obligation on a certificate holder to notify a chief officer of police when they intent to visit another force area in possession of their shotguns .
Acting Chief Inspector ████████ explained that on the Tuesday following Jairus’ death he briefed the national coordinator from the Firearms & Explosive Licencing Working Group to raise matters arising from the circumstances of Jairus’ death so there is awareness of the issues relating to second homes, however, there is no legal requirement for second homes to be declared by licence holders .
He further told the Court that in 2015, HM Inspection of Firearms Licencing recommended that forces must have a notification system on their local records to identify addresses and people where firearms are held. He explained that these systems are local rather than national and his recommendation to the Firearms & Explosive Licencing Working Group following Jairus’s death was that where an applicant declares a second home, the force where that home is located should be notified.
Dorset Police have taken action and put a system in place that when they are notified of the above, they will create a record on their system to flag the address as if that were a Dorset certificate holder, however it is not a legal requirement for forces to do this, and it is unknown if other forces nationally are doing this.
I therefore have concerns there is a lack of a system of sharing and flagging information between Police forces regarding shotgun licence holders and the location of shotguns, which could lead to future deaths.
Accordingly, emergency services may attend an address where shotguns are held without knowledge of that fact due to the lack of a marker being placed on the address. This causes a risk to all those attending unmarked addresses as they would potentially be ill prepared for what they could face which could lead to future deaths.
Additionally failing to have such markers on additional homes means that if the police are called to the address for other reasons such as a concern for welfare, they may miss the opportunity to put in place additional security measures ,or even revoke the licences, as required for the safety of the occupants at the address, and others. Evidence was heard that Dorset Police were called to Jairus’s family address in Dorset on the 28th March 2024 following a report that Jairus was missing. It was not apparent from the Police system at the time that there would be shotguns at the address. Jairus’s mental health was discussed during the report of this incident. Had the flag system been in place then, consideration could have been given to the continued possession of the shotgun in a property where Jairus could access them.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of police access to medical information about other residents during firearm and shotgun licence applications
Wider context from the report “(2) Further I have a concern around the access that police forces have to medical information about other persons living at the same property as the applicant, or at their second homes, when considering firearm and shotgun licence applications. Acting Chief Inspector ████████ advised the Court that whilst Police forces can look at the medical history of the applicant and can speak to others present at the address, they have no legal right to access the medical records of others residing at the property.
The medical history of Jairus came as great surprise to the attending Police officers at the Inquest. I am concerned that the lack of access to this medical information of others residing at the address of a licence applicant, especially in relation to mental health, when considering firearms or shotgun licence applications could lead to future deaths.
” 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 DHSC on access to household members’ health information and ways to mitigate associated firearms licensing risks.
Verbatim wording from the response “I am aware that you have also sent your Regulation 28 Report to the Secretary of State for Health and Social Care. That Department will be able to address and respond to the issue of the police having access to information about the health of persons other than those who are seeking to obtain a firearm or shotgun certificate. However, as this is a clear risk which has been identified, we will be engaging with the DHSC directly on this point and how to mitigate that risk despite the data protection and consent issues involved.” Source location Response from 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 Publish statutory guidance requiring police to consider the mental wellbeing of applicants and household members during firearms licensing home visits.
Verbatim wording from the response “Your second concern was about police access to medical information about other persons living at the same property as the applicant, or at their second homes, when considering firearm and shotgun licence applications. You will therefore wish to note that the most recent revision of the Statutory Guidance for Chief Officers of Police on firearms licensing, which was published on 5 August, now includes a specific requirement that the police should consider the mental wellbeing of both the applicant and other household members during home visits associated with an application for a firearm or shotgun licence.” Source location Response from 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 Amend firearm and shotgun applications to capture additional residences and update NFLMS to record those locations.
Verbatim wording from the response “light of your Regulation 28 Report, we will be amending the firearm and shotgun application form as soon as is practicable to request details of any second (or additional) residences where guns may be held, so that police are aware of where firearms are being stored, including where guns are being stored in different police force areas. This change to the application form will be implemented via Statutory Instrument and will also require a change to the NFLMS to ensure such details are recorded. We are therefore adding this change to planned adjustments to the system, which we expect to be completed in early 2026. In the meantime, this issue will be addressed by the police when undertaking suitability interviews with applicants or certificate holders.” Source location Response from 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 The Department of Health and Social Care will address police access to health information about people other than firearm or shotgun licence applicants.
Verbatim wording from the response “I am aware that you have also sent your Regulation 28 Report to the Secretary of State for Health and Social Care. That Department will be able to address and respond to the issue of the police having access to information about the health of persons other than those who are seeking to obtain a firearm or shotgun certificate. However, as this is a clear risk which has been identified, we will be engaging with the DHSC directly on this point and how to mitigate that risk despite the data protection and consent issues involved.” Source location Response from Home Office
Open published response
Concerns raised 6 Lack of restrictions on import of reportable substances View source Failure to consider whether sale purity and quantities are necessary for legitimate use View source Lack of domestic restrictions on purchase of reportable substances View source Lack of regulation and monitoring of substance use beyond the Poisons Act View source Lack of central monitoring of sodium nitrite poisoning incidents View source Sale of reportable substances at lethal purity and quantities View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of restrictions on import of reportable substances
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.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to consider whether sale purity and quantities are necessary for legitimate use
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.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of domestic restrictions on purchase of reportable substances
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.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of regulation and monitoring of substance use beyond the Poisons Act
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.
” 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 Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Sale of reportable substances at lethal purity and quantities
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.
” 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 the feasibility of additional regulatory and non-regulatory controls for the substance.
Verbatim wording from the response “includes targeted action on emerging methods of suicide. In recent months, my officials have been working with the Department of Health and Social Care (DHSC) and other departments to assess the feasibility of additional regulatory and non-regulatory levers for the substance in question. A cross-government workshop took place in June to explore these options. Further meetings will shortly be held between senior officials to agree recommendations for a coordinated government response.” Source location 2025-0346 Response from 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 Engage online platforms and retailers to promote responsible sales and voluntary removal of pure-form sales to the public.
Verbatim wording from the response “In the meantime, the Home Office continues to engage with industry to promote responsible sales practices. 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 retailers sales practices. For example, we encourage suppliers to use declaration of use forms for sales of potentially harmful substances. This work will continue to ensure suppliers are meeting their obligations under the Poisons Act.” Source location 2025-0346 Response from 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 Issue Border Force officers guidance on control actions for suspected suicide-related goods at the border.
Verbatim wording from the response “Moreover, to target potentially harmful acquisitions of this substance from overseas merchants, last year Border Force issued guidance to its officers about the control actions they must take, within existing legal provisions, if they receive any form of information suggesting that goods at the border contain items intended to assist with suicide. This relies on Border Force working closely with police forces and other relevant agencies to safeguard vulnerable individuals to the full extent possible. This work is complex, and Border Force will continue to monitor its policies, exploring opportunities to improve its ability to act where possible and to ensure that frontline Border Force staff who may encounter these items know what action to take and are supported on a case-by-case basis when required.” Source location 2025-0346 Response from 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 Monitor Border Force policies, explore improvements to intervention capability, and support frontline staff encountering these items.
Verbatim wording from the response “Moreover, to target potentially harmful acquisitions of this substance from overseas merchants, last year Border Force issued guidance to its officers about the control actions they must take, within existing legal provisions, if they receive any form of information suggesting that goods at the border contain items intended to assist with suicide. This relies on Border Force working closely with police forces and other relevant agencies to safeguard vulnerable individuals to the full extent possible. This work is complex, and Border Force will continue to monitor its policies, exploring opportunities to improve its ability to act where possible and to ensure that frontline Border Force staff who may encounter these items know what action to take and are supported on a case-by-case basis when required.” Source location 2025-0346 Response from 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 Border Force’s control actions for overseas acquisitions are limited to existing legal provisions.
Verbatim wording from the response “Moreover, to target potentially harmful acquisitions of this substance from overseas merchants, last year Border Force issued guidance to its officers about the control actions they must take, within existing legal provisions, if they receive any form of information suggesting that goods at the border contain items intended to assist with suicide. This relies on Border Force working closely with police forces and other relevant agencies to safeguard vulnerable individuals to the full extent possible. This work is complex, and Border Force will continue to monitor its policies, exploring opportunities to improve its ability to act where possible and to ensure that frontline Border Force staff who may encounter these items know what action to take and are supported on a case-by-case basis when required.” Source location 2025-0346 Response from 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 The Poisons Act reporting obligation does not apply to sellers based overseas.
Verbatim wording from the response “The substance in question is currently classified as a reportable substance under the Poisons Act 1972. While this requires GB-based sellers to report suspicious transactions, we acknowledge that this obligation does not apply to sellers based overseas. My officials are currently carrying out research into the availability of the substance in question, both domestically and internationally.” Source location 2025-0346 Response from Home Office
Open published response
8 Jul 2025 Peter Ramsden · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 1 Lack of emergency powers of entry for ambulance and fire services View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter Ramsden · 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
Peter Ramsden, who had not been seen for approximately two months, was found deceased in an advanced state of decomposition at his premises on 2 January 2025. The inquest concluded that his death was from natural causes, although no specific disease process was identified. The principal concern was a perceived gap in the law concerning powers of entry for ambulance and fire services when an incapacitated person may require urgent treatment.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of emergency powers of entry for ambulance and fire services
Wider context from the report “Evidence was heard that there is a lacuna in the law, specifically relating to section 17 of the Police & Criminal Evidence Act 1984 (PACE) which grants police officers the power to enter and search premises without a warrant in specific situations. These include, inter alia, entry for arrest and emergency situations which allows entry to save life or limb or prevent serious damage to a property. In this particular case, evidence was heard that this man had not been seen for two months and there were concerns about his welfare and paramedics attended on one occasion but have no powers of entry . Due to the Right Care, Right Person model, which has been developed over the last few years, the police did not get involved, as it was thought by the concerned individual that this man not being seen was due to a medical problem. Evidence was heard which suggested that on occasions, the ambulance service and the fire service should have powers of entry in the event that a person who is ill, unconscious or otherwise incapacitated, with a remediable disorder, can receive prompt and potentially life-saving treatment. In this case, causation would not have been established as the man has been dead for several weeks, but situations could and will arise where time-sensitive pathological processes require emergency treatment to save life .
” 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 Ambulance and Fire and Rescue services’ powers of entry fall outside the Home Office’s remit.
Verbatim wording from the response “Your letter raises issues around powers of entry for Ambulance services and Fire and Rescue services. I believe my officials had previously contacted your office to alert you that this is not within the remit of the Home Office but rather the Ministry of Housing, Communities and Local Government (lead on fire services) and Department for Health and Social Care (lead on paramedics). My officials have brought these matters to the attention of relevant colleagues from those departments.” Source location Response from 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 Ambulance and Fire and Rescue services’ powers of entry are matters for the responsible health and fire departments.
Verbatim wording from the response “Your letter raises issues around powers of entry for Ambulance services and Fire and Rescue services. I believe my officials had previously contacted your office to alert you that this is not within the remit of the Home Office but rather the Ministry of Housing, Communities and Local Government (lead on fire services) and Department for Health and Social Care (lead on paramedics). My officials have brought these matters to the attention of relevant colleagues from those departments.” Source location Response from Home Office
Open published response
23 May 2025 Matthew Joseph O’Reilly · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 9 Online availability of instructions for administering lethal poisons View source Online availability of information on sourcing lethal poisons and medicines View source Lack of specific seller guidance and training for one-off online marketplace purchases for self-harm View source Failure to evaluate small-quantity purchases for possible self-harm View source Failure to correctly evaluate small-quantity purchase patterns View source Online availability of information on accessing lethal poisons View source Lack of vendor awareness of potential self-harm misuse View source Failure of Home Office guidance materials to address deliberate suicide and self-harm misuse View source Lack of vendor awareness of website distribution on suicide-promotion platforms View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Online availability of instructions for administering lethal poisons
Wider context from the report “3. The police investigation revealed the ability of members of the public to access a number of websites, primarily created in the USA, Canada and Mexico that promoted information as to how to access:
a. Poisons that could bring about death
b. How, in what way and with other necessary preparations (in particular -antiemetic medications) the poisons should be administered .
c. Sourcing such poisons/chemicals/medicines in the UK and abroad.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Online availability of information on sourcing lethal poisons and medicines
Wider context from the report “3. The police investigation revealed the ability of members of the public to access a number of websites, primarily created in the USA, Canada and Mexico that promoted information as to how to access:
a. Poisons that could bring about death
b. How, in what way and with other necessary preparations (in particular -antiemetic medications) the poisons should be administered.
c. Sourcing such poisons/chemicals/medicines in the UK and abroad .
” 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 Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly evaluate small-quantity purchase patterns
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.).
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Online availability of information on accessing lethal poisons
Wider context from the report “3. The police investigation revealed the ability of members of the public to access a number of websites, primarily created in the USA, Canada and Mexico that promoted information as to how to access:
a. Poisons that could bring about death
b. How, in what way and with other necessary preparations (in particular -antiemetic medications) the poisons should be administered.
c. Sourcing such poisons/chemicals/medicines in the UK and abroad.
” 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 Home Office; that does not assign responsibility.
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.).
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of Home Office guidance materials 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 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 .
” 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 Home Office; that does not assign responsibility.
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.).
” Open source report
23 May 2025 William James Armstrong · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 7 Public access to websites promoting lethal poisons, administration methods and sourcing information View source Lack of vendor awareness of the substance’s potential misuse for suicide or self-harm View source Failure of Home Office guidance and supporting materials to address deliberate suicide or self-harm misuse View source Lack of specific guidance and training for sellers on one-off online-marketplace purchases for self-harm View source Failure of vendors to identify distribution of their website details on suicide-method platforms View source Failure to correctly evaluate small-quantity purchases View source Failure to evaluate small-quantity purchases for indications of suicide or self-harm View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Public access to websites promoting lethal poisons, administration methods and sourcing information
Wider context from the report “3. The police investigation revealed the ability of members of the public to access a number of websites , primarily created in the USA, Canada and Mexico that promoted information as to how to access:
a. Poisons that could bring about death
b. How, in what way and with which other necessary preparations (in particular -antiemetic medications) the poisons should be administered.
c. Sourcing such poisons/chemicals/medications in the UK and abroad.
” 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 Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of Home Office guidance and supporting materials to address deliberate suicide or 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 ████████ 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 .
” 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 Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of vendors to identify distribution of their website details on suicide-method 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 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.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly evaluate small-quantity 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 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.
” 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 Home Office; that does not assign responsibility.
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.
” Open source report
23 May 2025 Shaun Michael Bass · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 5 Public access to websites promoting poisons, administration methods and sourcing for suicide View source Failure to evaluate small-quantity purchases for potential suicide or self-harm use View source Lack of specific seller guidance and training on deliberate suicide or self-harm misuse of the substance View source Lack of vendor awareness of website distribution through platforms promoting suicide methods View source Lack of vendor awareness of the substance’s potential suicide or self-harm misuse View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Public access to websites promoting poisons, administration methods and sourcing for suicide
Wider context from the report “3. The police investigation revealed the ability of members of the public to access a number of websites, primarily created in the USA, Canada and Mexico that promoted information as to how to access:
a. Poisons that could bring about death
b. How, in what way and with what other necessary preparations (in particular -antiemetic medications) the poisons should be administered.
c. Sourcing such poisons/chemicals/medications in the UK or abroad.
” 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 Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of vendor awareness of website distribution through platforms promoting suicide methods
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.).
” 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 Home Office; that does not assign responsibility.
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.).
” Open source report
23 May 2025 Andrew Alexander Roger BROWN · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 9 Public access to instructions for administering poisons with necessary preparations View source Failure of vendors to identify distribution of their website details on suicide-method platforms View source 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 Lack of specific guidance and suggested training for sellers about one-off online purchases for self-harm View source Lack of vendor awareness of the substance’s potential suicide or self-harm misuse View source Public access to information on sourcing poisons and related substances View source Public access to websites providing information on poisons that could bring about death View source Failure of Home Office guidance materials to address deliberate suicide or self-harm misuse of the substance View source See 6 more concerns
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. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Public access to instructions for administering poisons with necessary preparations
Wider context from the report “3. The police investigation revealed the ability of members of the public to access a number of websites, primarily created in the USA, Canada and Mexico that promoted information as to how to access:
a. Poisons that could bring about death
b. How, in what way and with what other necessary preparations (in particular -antiemetic medications) the poisons should be administered.
c. Sourcing such poisons/chemicals/medicaments in the UK and abroad.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of vendors to identify distribution of their website details on suicide-method 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 ████████ 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.
” 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 Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Public access to information on sourcing poisons and related substances
Wider context from the report “3. The police investigation revealed the ability of members of the public to access a number of websites, primarily created in the USA, Canada and Mexico that promoted information as to how to access:
a. Poisons that could bring about death
b. How, in what way and with what other necessary preparations (in particular -antiemetic medications) the poisons should be administered.
c. Sourcing such poisons/chemicals/medicaments in the UK and abroad.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Public access to websites providing information on poisons that could bring about death
Wider context from the report “3. The police investigation revealed the ability of members of the public to access a number of websites, primarily created in the USA, Canada and Mexico that promoted information as to how to access:
a. Poisons that could bring about death
b. How, in what way and with what other necessary preparations (in particular -antiemetic medications) the poisons should be administered.
c. Sourcing such poisons/chemicals/medicaments in the UK and abroad.
” 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 Home Office; that does not assign responsibility.
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 .
” 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 Ofcom is responsible for regulating and enforcing online safety duties covering suicide-related illegal content on in-scope services.
Verbatim wording from the response “The Online Safety Act applies to services even if the companies providing them are overseas, should they have links to the UK. This includes if the service has a significant number of UK users, if the UK is a target market, or if it is capable of being accessed by UK users and there is a material risk of significant harm to such users.” 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 6 Lack of vendor awareness of suicide or self-harm misuse View source Failure to evaluate small-quantity purchases for suicide or self-harm intent View source Public access to websites providing information on obtaining and administering lethal poisons View source Failure of seller guidance and training to address deliberate suicide or self-harm misuse of reportable chemicals View source Failure to correctly evaluate increased small-quantity purchases for suicide or self-harm risk View source Failure to identify distribution of vendor websites and details on suicide-method platforms View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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. The report was sent to Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Public access to websites providing information on obtaining and administering lethal poisons
Wider context from the report “3. The police investigation revealed the ability of members of the public to access a number of websites , primarily created in the USA, Canada and Mexico that promoted information as to how to access:
a. Poisons that could bring about death
b. How, in what way and with other necessary preparations (in particular - antiemetic medications) the poisons should be administered.
c. Sourcing such poisons/chemicals in the UK and abroad.
” 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 Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to identify distribution of vendor websites and details on suicide-method 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 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.
” Open source report
23 May 2025 Samuel David Dickenson · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 7 Lack of specific seller guidance and training on one-off online purchases for self-harm View source Failure to evaluate small-quantity purchases for self-harm intent View source Failure to detect distribution of vendor website details on suicide-method platforms View source Public access to websites providing suicide-poison access, administration and sourcing information View source Lack of vendor awareness of potential self-harm misuse View source Incorrect evaluation of small-quantity purchases as recreational home-curing purchases View source Home Office guidance materials failing to address deliberate suicide and self-harm misuse View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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. The report was sent to Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to detect distribution of vendor website details on suicide-method 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 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.).
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Public access to websites providing suicide-poison access, administration and sourcing information
Wider context from the report “3. The police investigation revealed the ability of members of the public to access a number of websites, primarily created in the USA, Canada and Mexico that promoted information as to how to access:
a. Poisons that could bring about death
b. How, in what way and with what other necessary preparations (in particular -antiemetic medications) the poisons should be administered.
c. Sourcing such poisons/chemicals/medications in the UK and abroad.
” 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 Home Office; that does not assign responsibility.
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.).
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Incorrect evaluation of small-quantity purchases as recreational home-curing 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 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.).
” 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 Home Office; that does not assign responsibility.
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.
” 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 to encourage voluntary removal of high-purity sodium nitrite listings.
Verbatim wording from the response “While sodium nitrite remains widely used for legitimate purposes (e.g., food curing, industrial applications), retailers in Great Britain are legally obliged to report suspicious transactions under the Poisons Act 1972. Border Force officers have been issued guidance on identifying and intercepting consignments suspected for self-harm use. The Home Office also engages with online platforms to encourage voluntary removal of listings for high purity sodium nitrite.” Source location Response from 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 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
Open published response
23 May 2025 Mathew Anthony Price · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 7 Public access to websites promoting information on obtaining and administering poisons for suicide View source 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 Failure of Home Office guidance materials to address deliberate suicide or self-harm misuse of the substance View source Failure of vendors to know when their website details are distributed to promote suicide methods View source Lack of vendor awareness of the substance's potential suicide or self-harm misuse View source Lack of specific guidance and suggested training for sellers of the substance through online marketplaces View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Public access to websites promoting information on obtaining and administering poisons for suicide
Wider context from the report “3. The police investigation revealed the ability of members of the public to access a number of websites , primarily created in the USA, Canada and Mexico that promoted information as to how to access:
a. Poisons that could bring about death
b. How, in what way and with other necessary preparations (in particular -antiemetic medications) the poisons should be administered.
c. Sourcing such poisons/chemicals/medications in the UK and abroad.
” 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 Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
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 .
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of vendors to know when their website details are distributed to promote suicide methods
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.
” 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 Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
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.
” Open source report
23 May 2025 Kelly Michelle Walsh · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 9 Failure to evaluate small-quantity purchases for deliberate self-harm View source Public access to information on sourcing poisons, chemicals and medications View source Lack of specific guidance or training for sellers on one-off online-marketplace purchases for self-harm View source Lack of vendor awareness of potential self-harm misuse View source Incorrect evaluation of small-quantity purchases as recreational food-preservation purchases View source Failure of vendors to identify distribution of their website details on suicide-method platforms View source Failure of Home Office guidance materials to address deliberate misuse for suicide or self-harm View source Public access to information on administering poisons with necessary preparations View source Public access to websites providing information on poisons that could bring about death View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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. The report was sent to Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Public access to information on sourcing poisons, chemicals and medications
Wider context from the report “3. The police investigation revealed the ability of members of the public to access a number of websites, primarily created in the USA, Canada and Mexico that promoted information as to how to access:
a. Poisons that could bring about death
b. How, in what way and with other necessary preparations (in particular -antiemetic medications) the poisons should be administered.
c. Sourcing such poisons/chemicals/ medications in the UK and abroad.
” 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 Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Incorrect evaluation of small-quantity purchases as recreational 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 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.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of vendors to identify distribution of their website details on suicide-method 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 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.
” 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 Home Office; that does not assign responsibility.
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.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Public access to information on administering poisons with necessary preparations
Wider context from the report “3. The police investigation revealed the ability of members of the public to access a number of websites, primarily created in the USA, Canada and Mexico that promoted information as to how to access:
a. Poisons that could bring about death
b. How, in what way and with other necessary preparations (in particular -antiemetic medications) the poisons should be administered.
c. Sourcing such poisons/chemicals/ medications in the UK and abroad.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Public access to websites providing information on poisons that could bring about death
Wider context from the report “3. The police investigation revealed the ability of members of the public to access a number of websites, primarily created in the USA, Canada and Mexico that promoted information as to how to access:
a. Poisons that could bring about death
b. How, in what way and with other necessary preparations (in particular -antiemetic medications) the poisons should be administered.
c. Sourcing such poisons/chemicals/ medications in the UK and abroad.
” Open source report
16 Apr 2025 Abdulrahman AlAjmi · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 3 Absence of systems or structures for safe receipt and treatment of patients arriving in the UK for medical treatment View source Lack of a set procedure for UK hospital acceptance of patients from other countries View source Failure to ensure accurate and updated clinical information for referral acceptance and patient transfer View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Abdulrahman AlAjmi · 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
Abdulrahman AlAjmi died at the London Clinic on 7 August 2024 from multiorgan failure after arriving in the UK for medical treatment in a substantially poorer condition than had been reported. The report found that the flight probably contributed to his death by exacerbating serious pre-existing medical conditions. Concerns included the absence of uniform systems for accepting and transferring overseas patients, ensuring that receiving services have accurate and up-to-date medical information, and safely treating patients who arrive more unwell than anticipated.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Absence of systems or structures for safe receipt and treatment of patients arriving in the UK for medical treatment
Wider context from the report “5. The evidence showed an absence of systems or structures to ensure that patients arriving in the UK for medical treatment are able to be received (by the ambulance transferring them and the hospital treating them) safely and be properly treated : with a full understanding of the accurate and up to date medical position.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of a set procedure for UK hospital acceptance of patients from other countries
Wider context from the report “1. In the course of the evidence it was confirmed that there is no set procedure regarding the acceptance by hospitals in the UK of patients for treatment from other countries .
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accurate and updated clinical information for referral acceptance and patient transfer
Wider context from the report “2. It was stated in evidence that patients often arrive in a substantially different (often worse) condition to that described to the receiving clinicians when they accepted the referral and agreed that they were able to provide treatment. This means that UK health providers may receive for treatment individuals who are more unwell than anticipated, potentially requiring expertise that is not held by the receiving treatment providers (albeit in this case they had an ICU team who were able to provide the necessary treatment).
3. The evidence provided showed that it is up to each individual hospital to determine whether they are willing and able to accept a referral and agree the process for transfer of the patient. The evidence indicated that process is not uniform and relies heavily on the accuracy of the information received from the referring medical staff, as well as it being appropriately updated should circumstances change .
” Open source report
8 Apr 2025 Ruth Ann PINGREE · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 10 Lack of clear standards for achieving required fire-safety standards View source Lack of clear standards for required fire-safety measures View source Ad hoc fire-safety assurance and enforcement View source Lack of defined guidance, format, scope and frequency for fire-safety risk assessments View source Lack of required written fire-safety records View source Reliance on individual research ability to interpret fire-safety requirements View source Lack of clear standards for assessing applicable fire-safety measures View source Lack of required caravan fire-safety signage and emergency notices View source Failure to establish relevant fire-safety guidance as minimum standards View source Lack of specified intervals for maintenance inspections View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ruth Ann PINGREE · 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
Ruth Ann Pingree died after an accidental fire engulfed the caravan in which she was holidaying with her family. The caravan door became jammed, the smoke detector did not activate, and she was unable to escape before being overcome by fire fumes. The report raised concerns about a lack of clear standards for fire safety measures, risk assessments, and assurance and enforcement for businesses providing paid accommodation.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of clear standards for achieving required fire-safety standards
Wider context from the report “The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO).
In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO.
This does not require that the proprietors:
. keep any written records;
. set a specific interval of maintenance inspections; or
. provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency.
There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted.
Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take.
The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc.
This is in the context of businesses providing accommodation to the public on a paid basis.
There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard , and the assurance and enforcement mechanisms beyond this.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of clear standards for required fire-safety measures
Wider context from the report “The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO).
In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO.
This does not require that the proprietors:
. keep any written records;
. set a specific interval of maintenance inspections; or
. provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency.
There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted.
Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take.
The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc.
This is in the context of businesses providing accommodation to the public on a paid basis.
There is a lack of clear standards concerning what fire safety measures are required , how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Ad hoc fire-safety assurance and enforcement
Wider context from the report “The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO).
In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO.
This does not require that the proprietors:
. keep any written records;
. set a specific interval of maintenance inspections; or
. provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency.
There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted.
Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take.
The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc.
This is in the context of businesses providing accommodation to the public on a paid basis.
There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of defined guidance, format, scope and frequency for fire-safety risk assessments
Wider context from the report “The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO).
In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO.
This does not require that the proprietors:
. keep any written records;
. set a specific interval of maintenance inspections; or
. provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency.
There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted.
Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take.
The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc.
This is in the context of businesses providing accommodation to the public on a paid basis.
There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of required written fire-safety records
Wider context from the report “The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO).
In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO.
This does not require that the proprietors:
. keep any written records;
. set a specific interval of maintenance inspections; or
. provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency.
There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted.
Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take.
The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc.
This is in the context of businesses providing accommodation to the public on a paid basis.
There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Reliance on individual research ability to interpret fire-safety requirements
Wider context from the report “The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO).
In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO.
This does not require that the proprietors:
. keep any written records;
. set a specific interval of maintenance inspections; or
. provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency.
There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted.
Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take.
The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc.
This is in the context of businesses providing accommodation to the public on a paid basis.
There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of clear standards for assessing applicable fire-safety measures
Wider context from the report “The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO).
In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO.
This does not require that the proprietors:
. keep any written records;
. set a specific interval of maintenance inspections; or
. provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency.
There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted.
Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take.
The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc.
This is in the context of businesses providing accommodation to the public on a paid basis.
There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied , how to achieve that standard, and the assurance and enforcement mechanisms beyond this.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of required caravan fire-safety signage and emergency notices
Wider context from the report “The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO).
In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO.
This does not require that the proprietors:
. keep any written records;
. set a specific interval of maintenance inspections; or
. provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency.
There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted.
Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take.
The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc.
This is in the context of businesses providing accommodation to the public on a paid basis.
There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to establish relevant fire-safety guidance as minimum standards
Wider context from the report “The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO).
In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO.
This does not require that the proprietors:
. keep any written records;
. set a specific interval of maintenance inspections; or
. provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency.
There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted.
Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take.
The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc.
This is in the context of businesses providing accommodation to the public on a paid basis.
There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this.
” 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of specified intervals for maintenance inspections
Wider context from the report “The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO).
In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO.
This does not require that the proprietors:
. keep any written records;
. set a specific interval of maintenance inspections; or
. provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency.
There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted.
Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take.
The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc.
This is in the context of businesses providing accommodation to the public on a paid basis.
There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations