PFD report

Stella Elizabeth LeClaire · Prevention of Future Deaths report

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Issued 9 Dec 2025•Inner 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.

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. Advocacy of a substance for use in suicide
    Part of recurring concern: Uncontrolled promotion and supply of substances for suicide
  2. Sale of a substance for suicide use
    Part of recurring concern: Uncontrolled promotion and supply of substances for suicide
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.1

  1. Action

    Restrict public access to the substance through targeted operational work with suppliers, platforms and manufacturers, including action against concerning online sales.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 18 December 2025.

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

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. ”

Is this part of a recurring concern?

Yes — Uncontrolled promotion and supply of substances for suicide.

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

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. ”

Is this part of a recurring concern?

Yes — Uncontrolled promotion and supply of substances for suicide.

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

Restrict public access to the substance through targeted operational work with suppliers, platforms and manufacturers, including action against concerning online sales.

Verbatim wording from the response

“A significant part of the group’s work has focused on limiting public access to the substance involved in this and other cases, and more than 30 targeted actions have been taken to reduce opportunities to obtain it for non-legitimate purposes. These include operational work with online suppliers, platforms and manufacturers to raise safeguarding concerns, restrict availability, and prevent its sale in particularly concerning ways, including on online forums. Government departments have also worked with online platforms to reduce opportunities for the substance to be purchased by individuals. We are also exploring opportunities to work with Border Force, using existing legal provisions, to improve detection of packages that may be linked to vulnerable individuals.”

Source location

2025-0619 - Response from Department of Health and Social Care
Page 2 · response
Published 18 December 2025

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.3

  1. 1

    Operate the Concerning Methods Working Group to monitor emerging suicide-method trends and share intelligence across government and relevant sectors.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 18 December 2025.
  2. 2

    Continue working with the Chief Coroner’s Office through the Working Group to consider learning, coroners’ intelligence and suggestions for further action.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 18 December 2025.
  3. 3

    Explore working with Border Force under existing legal provisions to improve detection of packages potentially linked to vulnerable individuals.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 18 December 2025.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Decisions on issuing more consistent specialist toxicology guidance rest with the Chief Coroner.

    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 respondent action was interpreted

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

PFD Monitor interpretation

Operate the Concerning Methods Working Group to monitor emerging suicide-method trends and share intelligence across government and relevant sectors.

Verbatim wording from the response

“The Department recognises the importance of understanding emerging methods of suicide and the need to coordinate activity across government to reduce the risks they pose. As part of this work, we monitor concerning trends through the Concerning Methods Working Group, which brings together representatives from across government, policing, academia, the NHS and the voluntary sector. This group supports the rapid sharing of intelligence, including patterns that may be reflected in requests made by coroners for toxicology analysis, with the aim of enabling swift cross-government action where needed. The Working Group also includes representation from the coroner community, ensuring that learning from Prevention of Future Deaths reports forms an important part of how emerging risks are identified and addressed.”

Source location

2025-0619 - Response from Department of Health and Social Care
Page 1 · response
Published 18 December 2025

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 Chief Coroner’s Office through the Working Group to consider learning, coroners’ intelligence and suggestions for further action.

Verbatim wording from the response

“You also raise the question of whether more consistent guidance on obtaining specialist toxicology might support coroner investigations in these types of cases. As you will know, decisions on issuing guidance rest with the Chief Coroner. Your report has been shared with them, and the Department will continue to work closely with the Chief Coroner’s Office, which is represented on the Concerning Methods Working Group, to ensure that learning from PFD reports, intelligence from coroners, and suggestions for further action are fully considered within existing responsibilities.”

Source location

2025-0619 - Response from Department of Health and Social Care
Page 2 · response
Published 18 December 2025

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 working with Border Force under existing legal provisions to improve detection of packages potentially linked to vulnerable individuals.

Verbatim wording from the response

“A significant part of the group’s work has focused on limiting public access to the substance involved in this and other cases, and more than 30 targeted actions have been taken to reduce opportunities to obtain it for non-legitimate purposes. These include operational work with online suppliers, platforms and manufacturers to raise safeguarding concerns, restrict availability, and prevent its sale in particularly concerning ways, including on online forums. Government departments have also worked with online platforms to reduce opportunities for the substance to be purchased by individuals. We are also exploring opportunities to work with Border Force, using existing legal provisions, to improve detection of packages that may be linked to vulnerable individuals.”

Source location

2025-0619 - Response from Department of Health and Social Care
Page 2 · response
Published 18 December 2025

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

Decisions on issuing more consistent specialist toxicology guidance rest with the Chief Coroner.

Verbatim wording from the response

“You also raise the question of whether more consistent guidance on obtaining specialist toxicology might support coroner investigations in these types of cases. As you will know, decisions on issuing guidance rest with the Chief Coroner. Your report has been shared with them, and the Department will continue to work closely with the Chief Coroner’s Office, which is represented on the Concerning Methods Working Group, to ensure that learning from PFD reports, intelligence from coroners, and suggestions for further action are fully considered within existing responsibilities.”

Source location

2025-0619 - Response from Department of Health and Social Care
Page 2 · response
Published 18 December 2025

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
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Data last updated 7 September 2026