PFD report

NATASHA JENNIFER IRENE CRABB · Prevention of Future Deaths report

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Issued 13 Apr 2021•Surrey

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
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
4

Described in 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.

Report evidence summary

Concerns raised2

  1. Lack of restriction on the quantity of butane gas that can be purchased
    Part of recurring concern: Inadequate controls on the sale and online access to highly toxic substances
  2. Lack of legal powers to prevent capable people inhaling butane or remove butane from them
Responses linked to these concerns

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

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

  1. Position

    The Home Office is responsible for responding on powers applicable under the Psychoactive Substances Act 2016.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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

Lack of restriction on the quantity of butane gas that can be purchased

Wider context from the report

“2. There is no restriction on the amount of butane gas that can be purchased making it easy for a person addicted to inhaling butane gas to obtain large amounts of the gas at one time. ”

Is this part of a recurring concern?

Yes — Inadequate controls on the sale and online access to highly toxic substances.

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 prevent capable people inhaling butane or remove butane from them

Wider context from the report

“1. Inhaling butane is lawful and there are no legal powers to prevent a person with capacity inhaling butane nor to remove butane from them. The effects of inhalation can be fatal. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

The Home Office is responsible for responding on powers applicable under the Psychoactive Substances Act 2016.

Verbatim wording from the response

“Departmental officials have made contact with the Home Office, which will be providing a response to you in relation to the powers applicable under the Psychoactive Substances Act 2016.”

Source location

2021-0103-Response-from-Dept.-of-Health-and-Social-Care-Redacted
Page 1 · response
Published 13 April 2021

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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.4

  1. 1

    Fund RECONNECT care-after-custody services at £20 million annually by 2023/24.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 13 April 2021.
  2. 2

    Invest £2.5 million to pilot an enhanced RECONNECT care-after-custody service in several areas.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 13 April 2021.
  3. 3

    Introduce new integrated primary and community mental health care models backed by almost £1 billion of additional funding by 2023/24.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 13 April 2021.
  4. 4

    Invest at least £2.3 billion of extra funding annually in mental health services by 2023/24.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 13 April 2021.

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

Fund RECONNECT care-after-custody services at £20 million annually by 2023/24.

Verbatim wording from the response

“In relation to the wider context of your report, you may be interested to note that NHS England and NHS Improvement have developed their care after custody service, RECONNECT¹, to engage and support more people after their release from custody.”

Source location

2021-0103-Response-from-Dept.-of-Health-and-Social-Care-Redacted
Page 2 · response
Published 13 April 2021

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

Invest £2.5 million to pilot an enhanced RECONNECT care-after-custody service in several areas.

Verbatim wording from the response

“On 20 January 2021, the Government announced a new investment of £148 million to cut crime and protect people from the scourge of illegal drugs. As part of this package, £2.5 million will be invested in piloting an enhanced RECONNECT service in several areas of the country.”

Source location

2021-0103-Response-from-Dept.-of-Health-and-Social-Care-Redacted
Page 2 · response
Published 13 April 2021

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 new integrated primary and community mental health care models backed by almost £1 billion of additional funding by 2023/24.

Verbatim wording from the response

“Under the NHS Long Term Plan, we remain committed to investing at least £2.3 billion of extra funding a year in mental health services by 2023/24. New and integrated models of primary and community mental health care, backed by almost £1 billion extra by 2023/24, will give 370,000 adults with severe mental illnesses, including adults with a personality disorder, greater choice and control over their care and support to live well in their communities. In addition, the NHS has committed to ensure that 60 per cent of people with severe mental illness receive a comprehensive physical health-check and follow up, as part of the NHS Long Term Plan.”

Source location

2021-0103-Response-from-Dept.-of-Health-and-Social-Care-Redacted
Page 2 · response
Published 13 April 2021

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

Invest at least £2.3 billion of extra funding annually in mental health services by 2023/24.

Verbatim wording from the response

“This Government is committed to expanding and transforming mental health services and we recognise that providing the right interventions at the right time is vital to improving outcomes for people with mental health issues.”

Source location

2021-0103-Response-from-Dept.-of-Health-and-Social-Care-Redacted
Page 2 · response
Published 13 April 2021

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

Official responses located
1/2

Data last updated 7 September 2026