Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0002, written 4 Jan 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Jan 2021 |
|---|---|
| Reference | 2021-0002 |
| Deceased | Linda Gillchrest |
| Coroner | Richard Travers |
| Coroner area | County of Surrey |
| Category | Product related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquest Touching the Death of Linda Joan Gillchrest A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ THIS REPORT IS BEING SENT TO: 1. The Rt Hon Matt 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, TW9 1EJ 1 CORONER Mr Richard Travers, HM Senior Coroner for the County of Surrey 2 CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. 3 INVESTIGATION and INQUEST The inquest into the death of Linda Gillchrest was opened on 3rd September 2020. It was resumed and concluded on 18th December 2020. The medical cause of Mrs Gillchrest’s death was: Poisoning 1a. The inquest concluded with a short form conclusion of: Suicide. 4 CIRCUMSTANCES OF THE DEATH On the 19th July 2020 Linda Gillchrest was found by a neighbour in bed at her home address in Guildford, Surrey, there were no signs of life. She had not been seen for two days. The emergency services were called and RT4563 1 death was recognised at 23:31 hours that same day. A quantity of , which Mrs Gillchrest had bought on-line, was found in the bin situated in the kitchen at her home address. Toxicological tests found in her blood, which could not be explained high levels of by diet. Further, Mrs Gillchrest had bought an ebook which gave detailed and clear instructions as to how to self-administer a fatal dose of . 5 CORONER’S CONCERNS 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 same 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. The MATTERS OF CONCERN are that: • 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. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph one above have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. RT4563 2 Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 8 COPIES I have sent a copy of this report to the following: 1. See names in paragraph 1 above 2. 3. 4. 5. The Chief Coroner In addition to this report, I am 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 at the time of your response, about the release or the publication of your response by the Chief Coroner. Signed: Richard Travers Dated this 4th day of January 2021 RT4563 3
1 response 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
15 February 2021
Our Ref:
Mr Richard Travers
HM Senior Coroner, County of Surrey
HM Coroner's Court
Station Approach
Woking GU22 7AP
Dear Mr Travers
Thank you for your letter of 4 January 2021 to Matt Hancock concerning the death of Linda
Joan Gillchrest. I am responding as Minister with responsibility for mental health and
suicide prevention.
Firstly, I would like to say how deeply saddened I was to read of the troubling
circumstances surrounding Mrs Gillchrest’s death and I offer my heartfelt condolences to
her family and loved ones at this difficult time.
I note your concerns 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 Mrs Gillchrest. 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 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.
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 Mrs Gillchrest 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/
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