Prevention of Future Deaths reports · 2021

Linda Gillchrest

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 report4 Jan 2021
Reference2021-0002
DeceasedLinda Gillchrest
CoronerRichard Travers
Coroner areaCounty of Surrey
CategoryProduct related deaths · Suicide (from 2015)
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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. 

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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

Responses

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.

Response from Dept of Health and Social Care (PDF)
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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