Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0246, written 20 Nov 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Nov 2020 |
|---|---|
| Reference | 2020-0246 |
| Deceased | Jason Thompson |
| Coroner | Leslie Hamilton |
| Coroner area | County Durham and Darlington |
| Category | Suicide (from 2015) · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 M Hancock, MP, Secretary of State for Health and Social Care, 39 Victoria Street, London SW1H 0EU 2 EBAY UK Ltd, Hotham House, 1 Herron Square, Richmond upon Thames, London TW9 1EJ 3 Metalchem Limited, 492 Falmer Road, Brighton, United Kingdom, BN2 6LH 1 CORONER I am JR Leslie HAMILTON, Assistant Coroner for the area of County Durham and Darlington 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 Thirteenth February 2020 I commenced an investigation into the death of Jason THOMPSON aged 49. The investigation concluded at the end of the inquest on Twelfth November 2020. The conclusion of the inquest was Suicide: I a Hypoxaemia from Methaemoglobinaemia Poisoning I b I c II 4 CIRCUMSTANCES OF THE DEATH The deceased was a 49 year old man who collapsed at home, having taken a quantity of , and died shortly afterwards in Darlington Memorial Hospital on the 8th February 2020. He had been deeply affected by the death of his son and more recently by the death of friends, all by suicide. He had a history of attempts to harm himself often triggered by alcohol. He was getting support from mental health services. Twelve days before he died, he purchased meat preservative) without difficulty on mortem showed methaemoglobinaemia and toxicology showed an alcohol level of 178mg/100ml and , having researched its use on a in the urine. (a Post- 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) During the course of the inquest the evidence revealed matters giving rise to concern. The Toxicologist’s comments were particularly striking: “ minimum lethal dose is example, it is possibly to buy up to is used to preserve and cure meat, to which it imparts a pink-red colour. The . can be readily bought via the for a few pounds on For , without restriction. A chapter from , describes the use of .” and to commit suicide and compares it with Salts’, available 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. (1) breaking the criminal law by assisting suicide. may be actively promoting a particular method of death by suicide and hence (2) That such a lethal substance , sold by a company ( ) should be so freely available on a popular ) under the guise of being a meat preservative. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have 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 15 January 2021. 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 who may find it useful or of interest. Mr Ms N Persaud Tees, Esk and Wear Valley NHS Foundation Trust DS , Durham Constabulary 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 JR Leslie HAMILTON Assistant Coroner for County Durham and Darlington Dated: 20 November 2020
3 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
From Nadine Dorries MP Minister of State for Patient Safety, Suicide Prevention and Mental Health 39 Victoria Street London SW1H 0EU JR Leslie Hamilton HM Assistant Coroner, County Durham and Darlington HM Coroner's Office PO BOX 282 Bishop Auckland DL14 4FY 15 February 2021 Dear Mr Hamilton Thank you for your letter of 20 November 2020 to Matt Hancock concerning the death of Jason Thompson. I am responding as Minister with responsibility for mental health and suicide prevention and I am grateful for the additional time in which to do so. Firstly, I would like to say how deeply saddened I was to read of the troubling circumstances surrounding Mr Thompson’s death and I offer my heartfelt condolences to his family and loved ones at this difficult time. I note your concerns and those of the toxicologist in this case that information about suicide methods is so readily available on the Internet and that the means to assist suicide with this substance can be easily sourced and bought online. I wish to assure you that suicide prevention is a priority for this Government and we are working across local and national government to reduce suicide rates so that fewer such tragedies occur each year. 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. 1 https://www.gov.uk/government/publications/suicide-prevention-strategy-for-england 2 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/772210/n ational-suicide-prevention-strategy-workplan.pdf I am advised that suicide prevention policy leads in the health system, at the Department of Health and Social Care, Public Health England (PHE), and NHS England and NHS Improvement (NHSEI), are alert to the risk posed by websites promoting suicide methods, and their direction on the use of certain chemicals in completing suicide, including the substance taken by Mr Thompson. These organisations, along with key stakeholders and academics, are looking at what data is available on suicides by this method and at what steps we can take to stop further loss of life by this method. The concerns that Mr Thompson’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. There is work already taking place that directly and indirectly impacts some areas of concern. As you may be aware, in 2019, DCMS published its Online Harms White Paper4, which set out a range of legislative and non-legislative measures detailing how the Government is planning to tackle online harms, including harmful materials on self-harm and suicide. On 15 December 2020, DCMS published its response to the White Paper consultation, setting out how the proposed legal duty of care on online companies will work in practice and gives them new responsibilities towards their users. DCMS also announced that the Government has asked the Law Commission to examine how criminal law will address the encouragement, assistance and incitement of self-harm. In relation to your concerns about the chemical that Mr Thompson procured online, I understand that the HO has produced guidance for businesses on the sale of explosives precursors and poisons5. This includes the substance used in this case, which is a reportable poison under the Poisons Act 19726. This means that it is generally available to members of the public without the need for a licence, but sellers, including online sellers, are obligated to make suspicious transaction reports where they have grounds to believe that the sale is for an illicit use. The HO regularly engages with suppliers to help them meet their requirements under the Poisons Act and provide detailed guidance in relation to any additional safeguarding steps they may wish to take. Generally online marketplaces maintain their own policies on 3 Guidance: supplying explosives precursors and posions https://www.gov.uk/government/publications/supplying-explosives-precursors/supplying-explosives- precursors-and-poison 4 https://www.gov.uk/government/consultations/online-harms-white-paper 5 https://www.gov.uk/government/publications/supplying-explosives-precursors/supplying-explosives- precursors-and-poison 6 https://www.legislation.gov.uk/ukpga/1972/66 prohibited items, many of which will include a prohibition on the sale of poisons. It is the seller’s obligation to check that items they are listing are permitted by their own policies and to take any action where it is appropriate. 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 what can be done to get specialist support to those who might be at risk. 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. 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. Furthermore, PHE is piloting a national real-time surveillance system to monitor suspected suicide, by collecting early real time data which can be used to identify patterns of risk and causal factors, to inform national and local responses. HM Treasury has announced £1.2million funding to help support the development of the national system. Finally, we know how crucial it is that information about a suicide is treated with the utmost sensitivity it deserves, not only for the bereaved families and communities, but also because reporting on the particulars of an individual suicide can lead to other people taking their life in similar ways, be that in the same location or by the same method. With this in mind, and with due respect to the Chief Coroner’s rights under the Coroners (Investigations) Regulations 2013 to publish this response, I wish to reiterate the need for us, as far as possible, to ensure the media practice caution when making public any facts or details relating to this method. I hope this response is helpful. Thank you for bringing these concerns to my attention. 15 February 2021 NADINE DORRIES MINISTER OF STATE FOR PATIENT SAFETY, SUICIDE PREVENTION AND MENTAL HEALTH 7 https://www.longtermplan.nhs.uk/
EBAY (UK) LIMITED
1 MORE LONDON PLACE, LONDON, SE1 2AF
T +44 (0)20 7951 2000 F +44 (0)20 7951 1345
JR Leslie Hamilton
HM Coroner
County Durham and Darlington
PO Box 282
Bishop Auckland
County Durham
DL14 4FY
sent by email to hmcoroner@durham.gov.uk
8 January 2021
Dear Mr Hamilton
Re Jason Thompson (deceased) – Sodium Nitrite
I refer to your Regulation 28 Report dated 20 November 2020, and to your letter dated 3
December 2020 in which you enclosed the response of Metalchem Limited regarding the death
of Mr Jason Thompson.
May I first extend condolences on behalf of eBay to Mr Thompson’s relatives. This is indeed a
very tragic case.
By way of background, in 2019 eBay took the voluntary decision to prohibit globally the sale of
sodium nitrite as a chemical, after receiving a report of potential use of the substance for suicide
attempts. In addition to updating our prohibited items policy, eBay updated its filters, which are
used to help detect and prevent the listing for sale of this chemical.
To provide some context, eBay has approximately 1.6 billion listings live at any one time. It
therefore relies on utilising a combination of technology and live reporting from both monitoring
authorities and its users to help keep the marketplace as safe as practicable. Our expert internal
safety teams work in cooperation with various regulators across the world and in the UK, including
Westminster Trading Standards as our Prime Authority.
After we had received your first letter, our security team identified the listing from which Mr.
Thompson purchased the sodium nitrite. The listing had already ended. In addition, the security
team performed a sweep which revealed that no similar listings were found on our platform.
The listing was analysed in order to improve block filter algorithms. Since then, our security team
did not find any further listings of sodium nitrite. As you have seen, this was also the finding of
Metalchem Ltd in their letter to you dated 27 November 2020.
The nature of eBay means sellers create their own listing content. Therefore, although the filter
algorithm technology is highly effective, it is sometimes possible for unscrupulous or unaware
sellers to circumvent our policies and filters by utilising terminology that is not captured by the
current filter rules. That is why we continuously update our filters to make sure they remain as
effective as possible.
eBay also relies on a notice and takedown regime, where we are supported by members of the
public who can flag individual listings or sellers that are breaching policy, as well as receiving
intelligence from regulators such as Trading Standards and the Home Office.
EBAY (UK) LIMITED, REGISTERED IN ENGLAND AND WALES WITH NUMBER 03726028
EBAY (UK) LIMITED
1 MORE LONDON PLACE, LONDON, SE1 2AF
T +44 (0)20 7951 2000 F +44 (0)20 7951 1345
It is worth clarifying that sodium nitrite does occur as a legal ingredient in other products, such as
meat curing salts. These were highlighted in recent press articles as being available on eBay.
The amount of sodium nitrite in such products, at about 6%, is a small proportion of the overall
product compared to the amount of sodium chloride, which is itself injurious to health if consumed
in large quantities. Furthermore, the emetic effects of sodium chloride means that ingesting large
amounts of curing salts is likely to make an individual vomit. Therefore, after taking advice, we
have concluded that curing salts can continue to be sold on the site.
However, please be assured that we will continue to work with the relevant authorities to keep
abreast of developments and ensure that our policy prohibiting the sale of sodium nitrite as a
chemical will continue to be enforced rigorously. As you will be aware, sodium nitrite in its pure
form is still available for sale on the internet via other websites and platforms. We would therefore
support stricter regulations restricting the online sale of sodium nitrite as a chemical in its pure
form via the internet in order to prevent further such tragic cases in the future.
I am also copying this letter to the Secretary of State for Health.
Yours sincerely
Director
eBay (UK) Limited
EBAY (UK) LIMITED, REGISTERED IN ENGLAND AND WALES WITH NUMBER 03726028
Metalchem Limited 492 Falmer Road Brighton BN2 6LH East Sussex 27th November 2020 JR Leslie Hamilton H M Assistant Coroner County Durham & Darlington 4th Floor Civic Centre North Terrace Crook Co Durham DL15 9ES RE: Inquest into death of Jason Thompson Dear Mr Hamilton Thank you for your letter of 23rd November and copy of Regulation 28 Report to Prevent Future Deaths. I can confirm that Sodium Nitrite (which is used extensively in meat curing, preservation and in numerous chemical processes) is no longer sold by Metalchem on eBay. We withdrew the listing immediately back in April 2020 when we became aware that it was being recommended on these dreadful suicide forums for young people – notably – both of which are still sadly still active. I have also been in contact with the Home Office Protect team with regard to sales and processes: Detective Inspector CBRE Protect Team OSCT Home Office 5th Floor Peel 2 Marsham Street London SW1P 4DF I have since April proactively contacted a number of other sellers to request that they stop selling Sodium Nitrite NaNO2 (SN) online when clearly the reason for purchase cannot be reasonably ascertained. I have also enlisted the help of in removing a number of persistent sellers both on Ebay and then more recently this month on Etsy - and I regularly check these sites Metalchem Limited. Registered in England & Wales. Company Registration Number 12271592. Registered Office 492 Falmer Road Brighton BN2 6LH, East Sussex. As of today (when I have just checked) I am pleased to say that there are no listings for Sodium Nitrite on either eBay or Etsy . It is however still available on with shipping to United Kingdom. I will report this listing to do not show that they ship to the UK Screenshot below: as she has direct contacts in and is able to get these listings changed so they Screenshot 27/11/2020 Please do not hesitate to contact me if I can be of further help Yours faithfully Metalchem Limited. Registered in England & Wales. Company Registration Number 12271592. Registered Office 492 Falmer Road Brighton BN2 6LH, East Sussex.
See every Prevention of Future Deaths report matching Suicide (from 2015), and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.