David Honnor · Prevention of Future Deaths report

On the 25th April 2022, an investigation was commenced into the death of David Honnor, born on the 3rd March 1946.

The investigation concluded at the end of the Inquest on the 24th August 2022.

The Medical Cause of Death was:

1a Asphyxia.

The conclusion of the Inquest recorded

Suicide.

The deceased was diagnosed with oesophageal cancer in 2021. He underwent radiotherapy treatment. His condition worsened in 2022, he had a stent fitted in March 2022. On the 21st March 2022 he attended hospital and had a chest X ray. He was asked to return to the hospital later that day. He had obtained a ████████ gas canister, how and when is not clear.
████████ ████████ ████████ with the intention of ending his life.

1. During the inquest evidence was heard that:

i. Mr Honnor had researched on the internet how to obtain a ████████ gas canister with a view to ending his life.

ii. It is not known when or where he purchased this item.

iii. There is no restriction on members of the public purchasing these items.

iv. Separate consideration needs to be given to the labelling and colouring of gas cylinders to enable emergency services to respond to any risk arising at an incident.

v. The police found the vehicle with Mr Honnor in and the cannister. They removed him to commence CPR. The officers put themselves at risk in entering the vehicle which contained the gas cannister. Evidence was heard at the inquest from a police inspector that officers attending emergencies need to be able to identify gas cannisters by colour coding.

vi. The gas cylinder had the following labelling: ████████ ████████ and details the warnings of gas under pressure, odourless and asphyxiation- do not inhale. Non-inflammable, Non-toxic Gas2 with an emergency phone number.

2. I have concerns with regard to the following:

i. I have concerns that members of the public are able to purchase or acquire ████████.

ii. I have concerns that these products should be licensed.

iii. I have concerns that there is no colour coding of gas cylinders to assist first response emergency services.

iv. I have concerns as to whether the safety information on these gas cannisters is clear and sufficient.