PFD report

Dr Jonathan Harvey Shaw · Prevention of Future Deaths report

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Issued 25 Apr 2024•Manchester North

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
6

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
11

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised6

  1. Inability to retain consignments beyond the 30-day holding period
  2. Lack of training for joint working on managing overseas consignments of the substance
  3. Lack of national guidance on joint working for managing overseas consignments of the substance
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Remind frontline Border Force staff of required steps for relevant consignments and provide case-by-case support.

    Stated by Home OfficeStated in progressThe respondent said that this action was in progress when they made their response on 30 April 2024.
  2. Action

    Develop national guidance for Border Force and police on managing suspicious consignments and safeguarding vulnerable individuals.

    Stated by Home OfficeStated in progressThe respondent said that this action was in progress when they made their response on 30 April 2024.
  3. Action

    Engage police and legal colleagues to consider whether existing offences could support seizure powers in relevant cases.

    Stated by Home OfficeStated plannedThe respondent said that this action was planned when they made their response on 30 April 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Border Force cannot extend its seizure powers because those powers are limited by primary and secondary legislation.

    Stated by Home OfficeUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inability to retain consignments beyond the 30-day holding period

Wider context from the report

“The UK Border Force do not have the legal powers to seize a consignment of ████████ because it is not a prohibited poison under the Poisons Act 1972. If there is an ongoing police investigation or police interest in a particular consignment, the UK Border Force can use section 19 of the Police and Criminal Evidence Act 1984 to stop and hold. However the holding power is limited to 30 days, after which the consignment must be released. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of training for joint working on managing overseas consignments of the substance

Wider context from the report

“There is no national guidance or training provided to Police Forces or the UK Border Force on joint working around the management of ████████ from overseas which have been ordered by individuals inside the UK for the purpose of ending their own life. There is no legal requirement to alert the local police force before a consignment is released or to request a welfare check during which the recipient could be invited to agree to the safe destruction of the parcel by the police or UK Border Force. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of national guidance on joint working for managing overseas consignments of the substance

Wider context from the report

“There is no national guidance or training provided to Police Forces or the UK Border Force on joint working around the management of ████████ from overseas which have been ordered by individuals inside the UK for the purpose of ending their own life. There is no legal requirement to alert the local police force before a consignment is released or to request a welfare check during which the recipient could be invited to agree to the safe destruction of the parcel by the police or UK Border Force. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of a legal requirement to alert the local police force before releasing consignments

Wider context from the report

“There is no national guidance or training provided to Police Forces or the UK Border Force on joint working around the management of ████████ from overseas which have been ordered by individuals inside the UK for the purpose of ending their own life. There is no legal requirement to alert the local police force before a consignment is released or to request a welfare check during which the recipient could be invited to agree to the safe destruction of the parcel by the police or UK Border Force. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of a legal requirement to request a welfare check before releasing consignments

Wider context from the report

“There is no national guidance or training provided to Police Forces or the UK Border Force on joint working around the management of ████████ from overseas which have been ordered by individuals inside the UK for the purpose of ending their own life. There is no legal requirement to alert the local police force before a consignment is released or to request a welfare check during which the recipient could be invited to agree to the safe destruction of the parcel by the police or UK Border Force. ”

Is this part of a recurring concern?

Yes — Unreliable police concern-for-welfare procedures; Unreliable welfare-check request handling and follow-up.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of legal powers to seize consignments of the substance

Wider context from the report

“The UK Border Force do not have the legal powers to seize a consignment of ████████ because it is not a prohibited poison under the Poisons Act 1972. If there is an ongoing police investigation or police interest in a particular consignment, the UK Border Force can use section 19 of the Police and Criminal Evidence Act 1984 to stop and hold. However the holding power is limited to 30 days, after which the consignment must be released. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Remind frontline Border Force staff of required steps for relevant consignments and provide case-by-case support.

Verbatim wording from the response

“Similarly, Border Force are working at pace alongside police colleagues to introduce measures to prevent any similar tragedies occurring. This includes development of specific national guidance for managing suspicious items which is currently lacking and improved sharing of information with police forces, and other relevant agencies where required, to safeguard vulnerable individuals to the full extent possible within the limits of its existing powers. This work is complex and, whilst underway, frontline Border Force staff who may encounter these consignments are actively being reminded of the steps they need to take with additional support available on a case-by-case basis.”

Source location

Response from Home Office
Page 2 · response
Published 30 April 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop national guidance for Border Force and police on managing suspicious consignments and safeguarding vulnerable individuals.

Verbatim wording from the response

“Similarly, Border Force are working at pace alongside police colleagues to introduce measures to prevent any similar tragedies occurring. This includes development of specific national guidance for managing suspicious items which is currently lacking and improved sharing of information with police forces, and other relevant agencies where required, to safeguard vulnerable individuals to the full extent possible within the limits of its existing powers. This work is complex and, whilst underway, frontline Border Force staff who may encounter these consignments are actively being reminded of the steps they need to take with additional support available on a case-by-case basis.”

Source location

Response from Home Office
Page 2 · response
Published 30 April 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Engage police and legal colleagues to consider whether existing offences could support seizure powers in relevant cases.

Verbatim wording from the response

“Border Force, on whom the Regulation 28 Notice is focused, has no control over the extent of the powers granted to it by primary or secondary legislation but is working at pace with Home Office policy leads to understand how it can help to prevent similar tragedies occurring. Furthermore, Border Force will however engage with police and legal colleagues to consider whether powers can be invoked on behalf of police where other relevant offences may apply. For example:”

Source location

Response from Home Office
Page 2 · response
Published 30 April 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Explore legislative and policy options to control the substance and address ethical frontline responses to welfare concerns.

Verbatim wording from the response

“I am determined that we must ensure that all reasonable steps to prevent further loss of life are taken and the Home Office is actively exploring legislative and policy options, including working with or alongside officials of other Government Departments as appropriate, for the control of ████████ (and similar substances) including how to ensure front line officers respond ethically to circumstances where the welfare of individuals is concerned.”

Source location

Response from Home Office
Page 1 · response
Published 30 April 2024

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 cannot extend its seizure powers because those powers are limited by primary and secondary legislation.

Verbatim wording from the response

“As you have summarised, ████████ is not a substance requiring any special authority to import into the UK and so where it has been correctly declared, Border Force have no powers to seize it under the Customs and Excise Management Act 1979, (“CEMA 1979”). You have also highlighted how, Border Force’s CEMA powers are supplemented by the Police and Criminal Evidence Act 1984 (“PACE 1984”) where, in some cases, Border Force officers acting as designated customs officials can exercise powers granted under S19. This does allow for seizure provided that the substance is the consequence of an offence. Suicide/self-harm however are not criminal acts.”

Source location

Response from Home Office
Page 2 · response
Published 30 April 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. 1

    Support the National Crime Agency’s investigation into the supply of the substances, including collaboration with prosecuting and international authorities.

    Stated by National Police Chiefs’ CouncilStated completedThe respondent said that this action was complete when they made their response on 30 April 2024.
  2. 2

    Continue working with the Home Office and Department of Health and Social Care to explore options for preventing avoidable deaths.

    Stated by National Police Chiefs’ CouncilStated in progressThe respondent said that this action was in progress when they made their response on 30 April 2024.
  3. 3

    Disseminate preparedness information to chief constables, UK police forces and regional suicide-prevention leads.

    Stated by National Police Chiefs’ CouncilStated completedThe respondent said that this action was complete when they made their response on 30 April 2024.
  4. 4

    Raise awareness and inform policing responses about emerging suicide-related use of the substances.

    Stated by National Police Chiefs’ CouncilStated completedThe respondent said that this action was complete when they made their response on 30 April 2024.
  5. 5

    Engage across government to highlight the issue and support action addressing risks from the substance and similar substances.

    Stated by Home OfficeStated plannedThe respondent said that this action was planned when they made their response on 30 April 2024.
  6. 6

    Improve information sharing with police forces and relevant agencies about suspicious consignments and vulnerable individuals.

    Stated by Home OfficeStated in progressThe respondent said that this action was in progress when they made their response on 30 April 2024.
  7. 7

    Work with retailers to raise awareness of suspicious activity reporting obligations and share expertise to inform sales practices.

    Stated by Home OfficeStated in progressThe respondent said that this action was in progress when they made their response on 30 April 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.3

  1. 1

    The Home Office and DHSC lead cross-government suicide-prevention work, limiting NPCC responsibility for that work.

    Stated by National Police Chiefs’ CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. 2

    Police cannot generally enter or seize household self-harm items because applicable law is unclear and such items are ubiquitous.

    Stated by National Police Chiefs’ CouncilUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  3. 3

    Suicide prevention is treated as a public health issue led by the Department of Health and Social Care.

    Stated by Home OfficeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Support the National Crime Agency’s investigation into the supply of the substances, including collaboration with prosecuting and international authorities.

Verbatim wording from the response

“Through this work, we are aware of a number of international internet sites facilitating the purchase of ████████ and ████████ for the suspected purpose of suicide. In response to this threat and in collaboration with experts from the Department for Health and Social Care (DHSC), Home Office and other key stakeholders, the NPCC have raised awareness and informed responses across the policing sector regarding the emerging trend of ████████ and ████████ use in suicides. We have also supported the National Crime Agency, which is conducting a criminal investigation into the supply of ████████ by a specific foreign national and working closely with the CPS and international authorities.”

Source location

Response from NPCC
Page 1 · response
Published 30 April 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue working with the Home Office and Department of Health and Social Care to explore options for preventing avoidable deaths.

Verbatim wording from the response

“The NPCC remains committed to working with the Home Office and DHSC, who lead cross-government work on Suicide Prevention, to explore all options to prevent avoidable deaths. Furthermore, HM Government’s five-year Suicide Prevention Strategy for England, recently launched last year, contains numerous actions that will enable all relevant and influential organisations to support and achieve Government ambition.”

Source location

Response from NPCC
Page 2 · response
Published 30 April 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Disseminate preparedness information to chief constables, UK police forces and regional suicide-prevention leads.

Verbatim wording from the response

“In June 2023, ████████ wrote to all Chief Constables, highlighting the need for preparedness in addressing ████████ related challenges. Briefing materials were circulated to all UK police and regional suicide prevention leads. Furthermore, in October 2023, legislative changes were made regarding the sale of poisons and explosive precursors by suppliers based in England, Wales and Scotland. These changes, which include substances which are classed as reportable Explosive Precursors like ████████ or Poisons like ████████, aim to reduce the risk of harm by setting out obligations for suppliers related to regulated and reportable substances. As of 1st October 2023, it is now a criminal offence to sell certain substances without an Explosives Precursors and Poisons (EPP) license.”

Source location

Response from NPCC
Page 2 · response
Published 30 April 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Raise awareness and inform policing responses about emerging suicide-related use of the substances.

Verbatim wording from the response

“Through this work, we are aware of a number of international internet sites facilitating the purchase of ████████ and ████████ for the suspected purpose of suicide. In response to this threat and in collaboration with experts from the Department for Health and Social Care (DHSC), Home Office and other key stakeholders, the NPCC have raised awareness and informed responses across the policing sector regarding the emerging trend of ████████ and ████████ use in suicides. We have also supported the National Crime Agency, which is conducting a criminal investigation into the supply of ████████ by a specific foreign national and working closely with the CPS and international authorities.”

Source location

Response from NPCC
Page 1 · response
Published 30 April 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Engage across government to highlight the issue and support action addressing risks from the substance and similar substances.

Verbatim wording from the response

“Responsibility for the regulation of substances under the Poisons Act falls within the remit of the Home Office, however the policy objective for this legislation and associated regulations relates to counter-terrorism risk reduction aims rather than health considerations and as such ████████ has not been regulated. ████████ is also imported for legitimate purposes such as food preservation. In addition, as this Act criminalises both the seller and the buyer, which also presents difficulties around issues such as suicide, self harm or substance abuse. Suicide is treated as a public health issue and is led by the Department of Health and Social Care (DHSC). My officials will therefore engage across government to highlight the issue. I have also written to the Health Secretary to ask that they consider this issue as part of the Suicide Prevention Strategy.”

Source location

Response from Home Office
Page 3 · response
Published 30 April 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Improve information sharing with police forces and relevant agencies about suspicious consignments and vulnerable individuals.

Verbatim wording from the response

“Similarly, Border Force are working at pace alongside police colleagues to introduce measures to prevent any similar tragedies occurring. This includes development of specific national guidance for managing suspicious items which is currently lacking and improved sharing of information with police forces, and other relevant agencies where required, to safeguard vulnerable individuals to the full extent possible within the limits of its existing powers. This work is complex and, whilst underway, frontline Border Force staff who may encounter these consignments are actively being reminded of the steps they need to take with additional support available on a case-by-case basis.”

Source location

Response from Home Office
Page 2 · response
Published 30 April 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Work with retailers to raise awareness of suspicious activity reporting obligations and share expertise to inform sales practices.

Verbatim wording from the response

“████████ is a “reportable” poison listed in Part 4 of Schedule 1A of the Poisons Act, and therefore the Home Office work with retailers to raise awareness and emphasise their legal obligation to report suspicious activity for regulated and reportable substances. Our expertise in relation to substances of concern is also shared to inform their sales practices. The policy driver of the Poisons Act is to prevent terrorist use of explosives precursors or poisons so additionally, if, during the processing of suspicious activity reports, a safeguarding concern is identified by Counter Terrorism Policing, they will consider disseminating to police forces to consider a welfare check. Furthermore, the Act was amended in October 2023 to strengthen controls and enhance our suspicious activity reporting requirements, including new obligations for online marketplaces.”

Source location

Response from Home Office
Page 2 · response
Published 30 April 2024

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 and DHSC lead cross-government suicide-prevention work, limiting NPCC responsibility for that work.

Verbatim wording from the response

“The NPCC remains committed to working with the Home Office and DHSC, who lead cross-government work on Suicide Prevention, to explore all options to prevent avoidable deaths. Furthermore, HM Government’s five-year Suicide Prevention Strategy for England, recently launched last year, contains numerous actions that will enable all relevant and influential organisations to support and achieve Government ambition.”

Source location

Response from NPCC
Page 2 · response
Published 30 April 2024

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

Police cannot generally enter or seize household self-harm items because applicable law is unclear and such items are ubiquitous.

Verbatim wording from the response

“Regarding police powers of entry, search, and seizure, Section 19 of PACE allows for the seizure of ‘evidence’ when an offence is established or suspected. However, the offence of Encouraging or Assisting Suicide, as per the Suicide Act 1961 (amended 2010) is complex. This is particularly true when the perpetrator operates from outside the UK, and/or the 'victim' is an active and willing participant. In such scenarios, the law is unclear, and there is no power of entry to a victim’s premises unless an immediate threat to life is believed to exist under Section 17 of PACE. Identifying and seizing potential self-harm items in a typical household is impractical due to the ubiquity of such items.”

Source location

Response from NPCC
Page 2 · response
Published 30 April 2024

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

Suicide prevention is treated as a public health issue led by the Department of Health and Social Care.

Verbatim wording from the response

“Responsibility for the regulation of substances under the Poisons Act falls within the remit of the Home Office, however the policy objective for this legislation and associated regulations relates to counter-terrorism risk reduction aims rather than health considerations and as such ████████ has not been regulated. ████████ is also imported for legitimate purposes such as food preservation. In addition, as this Act criminalises both the seller and the buyer, which also presents difficulties around issues such as suicide, self harm or substance abuse. Suicide is treated as a public health issue and is led by the Department of Health and Social Care (DHSC). My officials will therefore engage across government to highlight the issue. I have also written to the Health Secretary to ask that they consider this issue as part of the Suicide Prevention Strategy.”

Source location

Response from Home Office
Page 3 · response
Published 30 April 2024

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026