Prevention of Future Deaths reports · 2020

Joseph Nihill

Regulation 28 report to prevent future deaths, reference 2020-0175, written 18 Sep 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report18 Sep 2020
Reference2020-0175
DeceasedJoseph Nihill
CoronerKevin McLoughlin
Coroner areaWest Yorkshire (East)
CategorySuicide (from 2015) · Other related deaths
Organisation namedLeeds and York Partnership NHS Foundation Trust
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28:  REPORT TO PREVENT FUTURE  DEATHS (1) 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS  BEING SENT TO: 

1.  Secretary of State for Health, Matt Hancock 

CORONER 

I am  Kevin Mcloughlin, Senior Coroner for the Coroner area of West Yorkshire (East) 

2 

CORONER'S LEGAL POWERS 

I make this report under paragraph 7,  Schedule 5,  of the Coroners and Justice Act 2009 
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

3 

INVESTIGATION and  INQUEST 

On 8 April 2020,  an investigation was commenced into the death of Joseph Francis Luke 
Nihill, aged 23. The investigation concluded at the end of the Inquest on  14 September 
2020. The conclusion of the Inquest was one of suicide caused  by 

 toxicity. 

4 

CIRCUMSTANCES OF THE DEATH 

On Saturday 4 April  2020, Joseph Francis Luke Nihill, aged 23,  was found  dead on the 
sofa in  the living room of his mother's home.  He had  left instructions not to touch  his 
body as  he had taken 
suicidal  intent. 

 to end  his life.  Farewell notes nearby confirmed  his 

An examination of his computer later revealed  he had  been in  contact with a 
gave him  advice on  methods of suicide.  It was suggested he consider '
the most popular method here and it's easy to obtain (most of the time)". 

  which 
,  and told "It's 

5 

CORONER'S CONCERNS 

During the course of the  Inquest the evidence revealed  matters giving rise to concern. 
In  my opinion there is  a risk that future deaths will occur unless action is taken.  In the 
circumstances it is my statutory duty to report to  you. 

The MATTERS OF CONCERN are as follows.  -

(1) 

 may be 
actively promoting a particular method of committing suicide and hence breaking 
the criminal law by assisting suicide.  Consideration should be given to blocking 
their availability in the UK so as to negate this risk. 

(2) 

 which enter discussions with troubled and vulnerable young 

men such as Joe Nihill serve to  undermine the benefit of both the medical 
treatment provided to him and the constructive efforts of his family to restore his 
health.  They have no social utility,  but do have the potential to cause harm. 

(3)  At a time when society is  seeking to safeguard the mental health particularly of 

young men suffering from  depression, it is counterproductive to permit such sites 
to bestow a legitimacy on self-harming behaviour.  There is  a foreseeable risk 
that other individuals will  be drawn into a deteriorating cycle by discussing 
methods of ending their lives. 

1 

 (4)  It is  harmful for potentially lethal substances to be  made available and promoted 
 could  be 

as an effective method of killing oneself.  In  this case,  Joe was told 
obtained for £8.  Those supplying relatively small amounts of
should  be  made aware of the implications of their trade. 

6 

ACTION  SHOULD BE  TAKEN 

In  my opinion action should  be taken to prevent future deaths and  I believe your 
organisation  has the power to take such action. 

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 25 November 2020.  I,  the Coroner,  may extend the period. 

Your response must contain details of action taken or proposed to  be taken,  setting out 
the timetable for action.  Otherwise you  must explain why no action is  proposed. 

8 

COPIES and  PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following  Interested 
Persons: 

1.  The family of Mr Joseph Francis Luke Nihill 
2.  West Yorkshire Police, for the attention of 
3.  Mr-
4.  The Coroners'  Society, for the attention of Senior Coroner Ms Nadia Persaud 
5.  Leeds and  York Partnership NHS Foundation Trust for attention of Ms 
6.  Metalchem  Limited, 492  Falmer Road,  Brighton,  BN2 6LH 

Safeguarding and  Domestic Violence Team,  Safer Leeds 

I am also under a duty to send the Chief Coroner a copy of your response. 

The Chief Coroner may publish either or both  in  a complete or redacted or summary 
form.  He may send  a copy of this report to any person who he believes may find  it useful 
or of interest.  You  may make representations to me,  the coroner,  at the time of your 
response,  about the release or the publication of your response by the Chief Coroner. 

9 

SIGNED BY SENIOR CORONER, KEVIN  MCLOUGHLIN 

Kev~~~k-

18 September 2020 

2

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