Shaun Michael Bass · Prevention of Future Deaths report

On 10 September 2020 I commenced an investigation into the death of Shaun Michael Bass aged 23. The investigation concluded at the end of the inquest on 11 August 2022.

The medical cause of death was determined to be;

1a. ████████ toxicity.

I returned a short form conclusion that Shaun Michael Bass died as the result of suicide.

Reporting restrictions were imposed in this case because of an ongoing criminal investigation in the United Kingdom, Europe and the United States of America, the case being one of a cluster of eight similar cases upon the Greater Manchester West jurisdiction.

Reporting restrictions were lifted on the 19th of April 2024.

This report is being published following updates from Greater Manchester Police and suicide prevention organisations received on the 14th of March 2025.

The deceased had a medical history that included persistent and enduring anxiety and depressive disorders that had required previous inpatient phases of treatment and care but had recently been treated and managed conservatively in the community.

On the 23rd of February 2020, the deceased was discovered collapsed and unresponsive in his residence at ████████, Bolton having ingested a significant quantity of ████████ that he had acquired earlier in the month from an internet-based company licensed to sell reportable poisons.

He was verified as dead and beyond further attempted resuscitation by attending paramedics. From within the premises, police recovered a note of intent recently handwritten by the deceased and empty packaging labelled '████████ - Extra Pure 99.9% 50g' - for meat curing' the deceased had sourced via accessing a website promoting and sanctioning self-harm by means of sodium nitrite poisoning. Post-mortem samples were analysed and confirmed the deceased had recently ingested a significant and fatal toxic quantity of sodium nitrate/nitrite.

The evidence established suboptimal elements in the mental healthcare and management of the deceased namely, a lack of continuity of personnel responsible for the deceased's care co-ordination, no mental health assessment review that was due to have taken place in November 2019, no adequate or immediate response to family concerns that had been communicated to health care professionals in January and February 2020. Whilst the consequence of the suboptimal healthcare in terms of bearing upon outcome cannot be evaluated, they represent a series of missed opportunities to record, discuss, review or adequately safeguard the deceased during a phase of deterioration in his mental health with the consequence that treating healthcare professionals failed to appreciate that the deceased was at an increased risk of self-harm.

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.

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.).

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.