PFD report

Linda Joan Gillchrest · Prevention of Future Deaths report

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Issued 4 Jan 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
3

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
8

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 raised3

  1. Failure to restrict purchase of lethal quantities from UK websites
    Part of recurring concern: Inadequate controls on the sale and online access to highly toxic substances
  2. Failure to restrict online purchase of publications containing detailed instructions to end a human life
  3. Lack of protection for vulnerable people before online purchases
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.3

  1. Action

    Work with government departments to explore further measures addressing this chemical and emerging suicide 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 14 January 2021.
  2. Action

    Invite Home Office officials to brief NHS, public health and suicide prevention partners on chemical-sale safeguards and support for people at risk.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 14 January 2021.
  3. Action

    Implement the Suicide Prevention Strategy and Cross-Government Suicide Prevention Workplan, including measures to reduce access to suicide 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 14 January 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Concerns about selling reportable substances fall within the Home Office’s policy remit.

    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

Failure to restrict purchase of lethal quantities from UK websites

Wider context from the report

“During the course of the inquest, evidence was heard that in May 2019 Mrs Gillchrest bought an e-book online from the USA, titled ████████ from a website of the same name. The book gave very clear and precise instructions as to how to self-administer a fatal dose of ████████, including the amount required and a timeline to death. In that month, for less than £5:00, pounds, Mrs Gillchrest purchased, on the auction site ‘www.ebay.co.uk’, a quantity of ████████ that was in excess of that recommended in ████████ as being required for a fatal dose. Both purchases were made without any restriction being imposed by the sellers. • A publication such as ████████, that contains detailed instructions as to how to end a human life, is available to be purchased online without restriction. • ████████ is available to be purchased in lethal quantities from a UK website for less than £5:00, again without restriction. • No protection is afforded to vulnerable people prior to them making such purchases. Consideration should be given to whether any steps can be taken to address the above concerns. ”

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

Failure to restrict online purchase of publications containing detailed instructions to end a human life

Wider context from the report

“During the course of the inquest, evidence was heard that in May 2019 Mrs Gillchrest bought an e-book online from the USA, titled ████████ from a website of the same name. The book gave very clear and precise instructions as to how to self-administer a fatal dose of ████████, including the amount required and a timeline to death. In that month, for less than £5:00, pounds, Mrs Gillchrest purchased, on the auction site ‘www.ebay.co.uk’, a quantity of ████████ that was in excess of that recommended in ████████ as being required for a fatal dose. Both purchases were made without any restriction being imposed by the sellers. • A publication such as ████████, that contains detailed instructions as to how to end a human life, is available to be purchased online without restriction. • ████████ is available to be purchased in lethal quantities from a UK website for less than £5:00, again without restriction. • No protection is afforded to vulnerable people prior to them making such purchases. Consideration should be given to whether any steps can be taken to address the above concerns. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 protection for vulnerable people before online purchases

Wider context from the report

“During the course of the inquest, evidence was heard that in May 2019 Mrs Gillchrest bought an e-book online from the USA, titled ████████ from a website of the same name. The book gave very clear and precise instructions as to how to self-administer a fatal dose of ████████, including the amount required and a timeline to death. In that month, for less than £5:00, pounds, Mrs Gillchrest purchased, on the auction site ‘www.ebay.co.uk’, a quantity of ████████ that was in excess of that recommended in ████████ as being required for a fatal dose. Both purchases were made without any restriction being imposed by the sellers. • A publication such as ████████, that contains detailed instructions as to how to end a human life, is available to be purchased online without restriction. • ████████ is available to be purchased in lethal quantities from a UK website for less than £5:00, again without restriction. • No protection is afforded to vulnerable people prior to them making such purchases. Consideration should be given to whether any steps can be taken to address the above concerns. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Work with government departments to explore further measures addressing this chemical and emerging suicide methods.

Verbatim wording from the response

“The concerns that Mrs Gillchrest’s death raises sit within the policy remits of a range of Government departments, including the Department for Digital, Culture, Media and Sports (DCMS) for its work on online harms; and the Home Office (HO) for its work on the sale of reportable substances³. Officials have shared your concerns with those Departments and are working with officials from those and other Government departments to explore what further steps we can take to prevent further tragedies, both for this chemical, and any other emerging methods.”

Source location

2021-0002-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
Page 2 · response
Published 14 January 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

Invite Home Office officials to brief NHS, public health and suicide prevention partners on chemical-sale safeguards and support for people at risk.

Verbatim wording from the response

“In addition to the cross-Government group set up to put in place steps to tackle emerging methods of suicide, officials at the Department of Health and Social Care have also invited HO officials to brief partners in NHSEI, PHE and suicide prevention stakeholders on what HO can do to ensure that sellers of these chemicals are aware of their potential use in suicide, and on what can be done to get specialist support to those who might be at risk.”

Source location

2021-0002-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
Page 3 · response
Published 14 January 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

Implement the Suicide Prevention Strategy and Cross-Government Suicide Prevention Workplan, including measures to reduce access to suicide methods.

Verbatim wording from the response

“We continue to take action to reduce suicide rates through the Suicide Prevention Strategy for England¹ and the first Cross-Government Suicide Prevention Workplan², which sets out an ambitious programme across national and local government and the NHS. The Workplan includes actions to reduce access to the means of suicide, including through harmful online content.”

Source location

2021-0002-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
Page 1 · response
Published 14 January 2021

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

Concerns about selling reportable substances fall within the Home Office’s policy remit.

Verbatim wording from the response

“The concerns that Mrs Gillchrest’s death raises sit within the policy remits of a range of Government departments, including the Department for Digital, Culture, Media and Sports (DCMS) for its work on online harms; and the Home Office (HO) for its work on the sale of reportable substances³. Officials have shared your concerns with those Departments and are working with officials from those and other Government departments to explore what further steps we can take to prevent further tragedies, both for this chemical, and any other emerging methods.”

Source location

2021-0002-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
Page 2 · response
Published 14 January 2021

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

Online-harms concerns fall within the Department for Digital, Culture, Media and Sport’s policy remit.

Verbatim wording from the response

“The concerns that Mrs Gillchrest’s death raises sit within the policy remits of a range of Government departments, including the Department for Digital, Culture, Media and Sports (DCMS) for its work on online harms; and the Home Office (HO) for its work on the sale of reportable substances³. Officials have shared your concerns with those Departments and are working with officials from those and other Government departments to explore what further steps we can take to prevent further tragedies, both for this chemical, and any other emerging methods.”

Source location

2021-0002-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
Page 2 · response
Published 14 January 2021

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.5

  1. 1

    Invest £57 million through the NHS Long Term Plan to support local suicide prevention plans and establish suicide bereavement services by 2023/24.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 14 January 2021.
  2. 2

    Provide almost £600,000 to help local authorities strengthen their suicide prevention plans.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 14 January 2021.
  3. 3

    Work with local government to assure the effectiveness of multi-agency suicide prevention plans.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 14 January 2021.
  4. 4

    Maintain a cross-government group addressing emerging suicide methods.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 14 January 2021.
  5. 5

    Share concerns about online suicide methods and chemical access with relevant government departments.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 14 January 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

Invest £57 million through the NHS Long Term Plan to support local suicide prevention plans and establish suicide bereavement services by 2023/24.

Verbatim wording from the response

“More generally, from 2019/20, we are investing £57million in suicide prevention through the NHS Long Term Plan⁷. This will see investment in all areas of the country by 2023/24 to support local suicide prevention plans and establish suicide bereavement support services.”

Source location

2021-0002-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
Page 3 · response
Published 14 January 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

Provide almost £600,000 to help local authorities strengthen their suicide prevention plans.

Verbatim wording from the response

“In addition, every local authority now has a multi-agency suicide prevention plan in place. We are working with local government to assure the effectiveness of those plans, and we invested almost £600,000 in 2019/20 to support local authorities to strengthen their plans.”

Source location

2021-0002-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
Page 3 · response
Published 14 January 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

Work with local government to assure the effectiveness of multi-agency suicide prevention plans.

Verbatim wording from the response

“In addition, every local authority now has a multi-agency suicide prevention plan in place. We are working with local government to assure the effectiveness of those plans, and we invested almost £600,000 in 2019/20 to support local authorities to strengthen their plans.”

Source location

2021-0002-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
Page 3 · response
Published 14 January 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

Maintain a cross-government group addressing emerging suicide methods.

Verbatim wording from the response

“In addition to the cross-Government group set up to put in place steps to tackle emerging methods of suicide, officials at the Department of Health and Social Care have also invited HO officials to brief partners in NHSEI, PHE and suicide prevention stakeholders on what HO can do to ensure that sellers of these chemicals are aware of their potential use in suicide, and on what can be done to get specialist support to those who might be at risk.”

Source location

2021-0002-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
Page 3 · response
Published 14 January 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

Share concerns about online suicide methods and chemical access with relevant government departments.

Verbatim wording from the response

“The concerns that Mrs Gillchrest’s death raises sit within the policy remits of a range of Government departments, including the Department for Digital, Culture, Media and Sports (DCMS) for its work on online harms; and the Home Office (HO) for its work on the sale of reportable substances³. Officials have shared your concerns with those Departments and are working with officials from those and other Government departments to explore what further steps we can take to prevent further tragedies, both for this chemical, and any other emerging methods.”

Source location

2021-0002-Response-from-Dept-of-Health-and-Social-Care-Redacted.pdf
Page 2 · response
Published 14 January 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

Data last updated 7 September 2026