PFD report

Darren Mindham · Prevention of Future Deaths report

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Issued 3 May 2016•South London

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.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

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 raised1

  1. Lack of strict control over pentobarbital
    Part of recurring concern: Inadequate safeguards for access to dangerous drugs
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.2

  1. Position

    Drug classification and scheduling are not matters for the Department of Health.

    Stated by Department of Health and Social CareOutside remitThe respondent said that this matter was outside its role or authority.

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 strict control over pentobarbital

Wider context from the report

“Pentobarbital is a drug that is found in Schedule 3 of the Misuse of Drugs Regulations 2001, and is therefore not subject to the strict control found in Schedule 2. Whilst there may be practical difficulties in complying with stricter control, the use of pentobarbital in suicide has become commonplace. It has been shown that reducing access to the means of suicide can be effective in reducing the rate of suicide. ”

Is this part of a recurring concern?

Yes — Inadequate safeguards for access to dangerous drugs.

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Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Drug classification and scheduling are not matters for the Department of Health.

Verbatim wording from the response

“This is not however a matter for the Department of Health. The Advisory Council on the Misuse of Drugs (ACMD) makes recommendations to government on the control of dangerous or otherwise harmful drugs, including classification and scheduling under the Misuse of Drugs Act 1971 and its regulations. ACMD is an advisory non-departmental public body, sponsored by the Home Office and is the lead organisation in this area. I would therefore advise that you re-direct your Regulation 28 letter to the following contact for a response on this matter.”

Source location

2016-0170-Response-by-Department-of-Health
Page 1 · response
Published 3 May 2016

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Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

The Advisory Council on the Misuse of Drugs, sponsored by the Home Office, is responsible for recommendations on drug classification and scheduling.

Verbatim wording from the response

“This is not however a matter for the Department of Health. The Advisory Council on the Misuse of Drugs (ACMD) makes recommendations to government on the control of dangerous or otherwise harmful drugs, including classification and scheduling under the Misuse of Drugs Act 1971 and its regulations. ACMD is an advisory non-departmental public body, sponsored by the Home Office and is the lead organisation in this area. I would therefore advise that you re-direct your Regulation 28 letter to the following contact for a response on this matter.”

Source location

2016-0170-Response-by-Department-of-Health
Page 1 · response
Published 3 May 2016

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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.3

  1. 1

    Continue discussions with the Medicines and Healthcare Products Regulatory Agency about practical steps concerning medicines used in suicide.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 3 May 2016.
  2. 2

    Reduce access to paracetamol as a means of suicide.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 3 May 2016.
  3. 3

    Continually monitor suicide data for trends and emerging methods.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 3 May 2016.

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 discussions with the Medicines and Healthcare Products Regulatory Agency about practical steps concerning medicines used in suicide.

Verbatim wording from the response

“or observe a new method emerging, we will take appropriate action to reduce access to the means of suicide. One example where we have been successful is in reducing access to paracetamol as a means of suicide. Of course, other drugs are also used in suicide. We continue to have discussions with the Medicines and Healthcare Products Regulatory Agency about practical steps that could be taken in relation to medicines used in suicide.”

Source location

2016-0170-Response-by-Department-of-Health
Page 2 · response
Published 3 May 2016

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Reduce access to paracetamol as a means of suicide.

Verbatim wording from the response

“or observe a new method emerging, we will take appropriate action to reduce access to the means of suicide. One example where we have been successful is in reducing access to paracetamol as a means of suicide. Of course, other drugs are also used in suicide. We continue to have discussions with the Medicines and Healthcare Products Regulatory Agency about practical steps that could be taken in relation to medicines used in suicide.”

Source location

2016-0170-Response-by-Department-of-Health
Page 2 · response
Published 3 May 2016

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Continually monitor suicide data for trends and emerging methods.

Verbatim wording from the response

“With regard to methods of suicide, the Department of Health continually monitors trends in suicide data. Where we identify an increase in a particular method of suicide”

Source location

2016-0170-Response-by-Department-of-Health
Page 1 · response
Published 3 May 2016

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