Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0223, written 25 Apr 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Apr 2024 |
|---|---|
| Reference | 2024-0223 |
| Deceased | Jonathan Shaw |
| Coroner | Catherine McKenna |
| Coroner area | Manchester North |
| Category | 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.
Ms Catherine McKenna Greater Manchester North Area Coroner HM Coroner’s Office Floors 2 & 3 Newgate House Rochdale OL16 1AT By email only: FAO Ms Catherine McKenna Date: 11th June 2024 Dear Ms McKenna,, Regulation 28 Report – Dr Jonathan Harvey Shaw I write on behalf of the National Police Chiefs Council (NPCC) in relation to paragraph 7, Schedule 5 of the Coroners and Justice Act 2009, and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, in relation to the prevention of future deaths report sent via email to the NPCC dated 25th April 2024. The notice sets out concerns that arose from the information received during the inquest into the death of Dr Shaw. I am very sorry to read of the circumstances of Dr Shaw’s death. My sympathies are with his family and friends. The NPCC is an advisory body that supports policy development for police forces in England & Wales through a set of portfolios. ACC Prevention and Chair NPCC Suicide Prevention Steering Group. is the National Police Chief Council’s lead for Suicide and Through this work, we are aware of a number of international internet sites facilitating the purchase for the suspected purpose of suicide. In response to this threat and in of collaboration with experts from the Department for Health and Social Care (DHSC), Home Office and other key stakeholders, the NPCC have raised awareness and informed responses across the policing sector regarding the emerging trend of supported the National Crime Agency, which is conducting a criminal investigation into the supply of use in suicides. We have also and by a specific foreign national and working closely with the CPS and international authorities. As you may be aware, and are ‘reportable’ substances in the UK ( as an Explosive Precursor and Given the threat posed by these substances, as a Reportable Poison) under the Poisons Act. has discussed the regulation or restriction of with the Home Office’s Chemical Reporting Team and the Dept of Health and and Social Care. These agencies have taken work forward to ensure as far as possible that both 1st Floor, 10 Victoria Street, London SW1H 0NN | | www.npcc.police.uk and is not sold to individuals. Legal suppliers have been directed to mix the substances with other products namely salt which will lead to vomiting upon ingestion, thereby reducing the viability of there are no current plans to change Office, in collaboration with legitimate suppliers, is proactively challenging suspicious sales. as a suicide method. We have been advised that status from 'reportable'. The Home or or wrote to all Chief Constables, highlighting the need for preparedness in related challenges. Briefing materials were circulated to all UK police and In June 2023, addressing regional suicide prevention leads. Furthermore, in October 2023, legislative changes were made regarding the sale of poisons and explosive precursors by suppliers based in England, Wales and Scotland. These changes, which include substances which are classed as reportable Explosive Precursors like setting out obligations for suppliers related to regulated and reportable substances. As of 1st October 2023, it is now a criminal offence to sell certain substances without an Explosives Precursors and Poisons (EPP) license. , aim to reduce the risk of harm by or Poisons like When specific intelligence indicates that an identifiable individual in the UK has purchased items like and , police will conduct a ‘safe and well’ visit. Often, voluntary surrender of these items can be negotiated, with recovery and appropriate support referrals made. Where this is not possible, increased health surveillance measures are encouraged with partner agencies. In cases of death linked to chemical suicide, efforts are made to track shipments and download electronic devices to quickly identify the product's origin and prevent further victims. Regarding police powers of entry, search, and seizure, Section 19 of PACE allows for the seizure of ‘evidence’ when an offence is established or suspected. However, the offence of Encouraging or Assisting Suicide, as per the Suicide Act 1961 (amended 2010) is complex. This is particularly true when the perpetrator operates from outside the UK, and/or the 'victim' is an active and willing participant. In such scenarios, the law is unclear, and there is no power of entry to a victim’s premises unless an immediate threat to life is believed to exist under Section 17 of PACE. Identifying and seizing potential self-harm items in a typical household is impractical due to the ubiquity of such items. The NPCC remains committed to working with the Home Office and DHSC, who lead cross- government work on Suicide Prevention, to explore all options to prevent avoidable deaths. Furthermore, HM Governments five-year Suicide Prevention Strategy for England, recently launched last year, contains numerous actions that will enable all relevant and influential organisations to support and achieve Government ambition. I hope the information provided will go some way to address your concerns. For any further information please contact my Staff Officer ( who will be happy to address any concerns and answer any questions. ) Yours sincerely, Chair, National Police Chiefs’ Council
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. , Chair of the National Police Chiefs Council 2. The Rt Hon James Cleverly MP, Secretary of State for the Home Office (Border Force) CORONER I am Catherine McKenna, Area Coroner for the Coroner Area of Manchester North 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 3 INVESTIGATION and INQUEST On 6 December 2023 an investigation into the death of Dr Jonathan Harvey Shaw was commenced. The investigation concluded at the end of the inquest on 24 April 2024. I recorded a conclusion of Suicide. The medical cause of death was 1a) fatal nitrite/nitrate toxicity. 4 CIRCUMSTANCES OF DEATH Dr Jonathan Shaw took his own life through the intentional ingestion through an online purchase from a company that operates in Malaysia. Before the package was delivered to Dr Shaw, it had been stopped by UK Border Force at the request of the National Fast Parcel Targeting Team who received intelligence about the Malaysian company and information about concerns for Dr Shaw’s welfare and the risk to life. which he had procured Officers from Greater Manchester Police (GMP) made contact with Dr Shaw and informed him that the parcel had been stopped by UK Border Force. There is no evidence that the officers were informed by UK Border Force of the timescales before release and the officers would most likely not have been aware that UK Border Force could only lawfully keep hold of the package for 30 days. UK Border Force released the package 9 days after its arrival in the UK and without examining its contents or consulting with GMP. The lack of consultation with GMP represented a significant missed opportunity as the evidence was that Dr Shaw would most likely have agreed to the safe destruction of the package if he had been asked at a point before he took physical possession of it. In the event, Dr Shaw concealed the package and informed his family, the police and mental health professionals that he had disposed of it. He subsequently used the contents of the package to end his life. 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 MATTER OF CONCERN is as follows:- The UK Border Force do not have the legal powers to seize a consignment of a prohibited poison under the Poisons Act 1972. If there is an ongoing police investigation or police interest in a particular consignment, the UK Border Force can use section 19 of the Police and Criminal Evidence Act 1984 to stop and hold. However the holding power is limited to 30 days, after which the consignment must be released. because it is not There is no national guidance or training provided to Police Forces or the UK Border Force on joint working around the management of consignments of from overseas which have been ordered by individuals inside the UK for the purpose of ending their own life. There is no legal requirement to alert the local police force before a consignment is released or to request a welfare check during which the recipient could be invited to agree to the safe destruction of the parcel by the police or UK Border Force. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe each of you respectively 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 21 June 2024 I, the Area 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 namely:- • The family of Dr Shaw I have also sent a copy of my report to the following organisations who may find its contents of interest:- • Greater Manchester Police • National Suicide Prevention Strategy Advisory Group 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 from. 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. - Date: 25 April 2024 Signed:
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.
Home Secretary 2 Marsham Street London SW1P 4DF www.homeoffice.gov.uk Ms Catherine McKenna HM Area Coroner for Greater Manchester North Dear Ms McKenna, 27 September 2024 Dr JONATHAN HARVEY SHAW REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Thank you for your Regulation 28 report, dated 25 April 2024, that was sent to my predecessor following the inquest into the tragic death of Dr Shaw who died on 2 December 2023. I am very grateful to you for sharing your findings, and for the opportunity to reflect as the new Home Secretary on the processes that were in place around the time of Dr Shaw’s death. Your report has identified the following matters of joint concern to the Home Office, which you suggest has the potential to lead to future deaths, if left unaddressed: • The UK Border Force do not have the legal powers to seize a consignment of because it is not a prohibited poison under the Poisons Act 1972. If there is an ongoing police investigation or police interest in a particular consignment, the UK Border Force can use section 19 of the Police and Criminal Evidence Act 1984 to stop the consignment and hold it. However, the holding power is limited to 30 days, after which the consignment must be released. • There is no national guidance or training provided to Police Forces or the UK Border Force on joint working around the management of consignments of from overseas which have been ordered by individuals inside the UK for the purpose of ending their own life. There is no legal requirement to alert the local police force before a consignment is released or to request a welfare check during which the recipient could be invited to agree to the safe destruction of the parcel by the police or UK Border Force. I am determined that we must ensure that all reasonable steps to prevent further loss of life are taken and the Home Office is actively exploring legislative and policy options, including working with or alongside officials of other Government Departments as appropriate, for the control of (and similar substances) including how to ensure front line officers respond ethically to circumstances where the welfare of individuals is concerned. 1 A3 is not a substance requiring any special As you have summarised, authority to import into the UK and so where it has been correctly declared, Border Force have no powers to seize it under the Customs and Excise Management Act 1979, (“CEMA 1979”). You have also highlighted how, Border Force’s CEMA powers are supplemented by the Police and Criminal Evidence Act 1984 (“PACE 1984") where, in some cases, Border Force officers acting as designated customs officials can exercise powers granted under S19. This does allow for seizure provided that the substance is the consequence of an offence. Suicide/self-harm however are not criminal acts. is a “reportable” poison listed in Part 4 of Schedule IA of the Poisons Act, and therefore the Home Office work with retailers to raise awareness and emphasise their legal obligation to report suspicious activity for regulated and reportable substances. Our expertise in relation to substances of concern is also shared to inform their sales practices. The policy driver of the Poisons Act is to prevent terrorist use of explosives precursors or poisons so additionally, if, during the processing of suspicious activity reports, a safeguarding concern is identified by Counter Terrorism Policing, they will consider disseminating to police forces to consider a welfare check. Furthermore, the Act was amended in October 2023 to strengthen controls and enhance our suspicious activity reporting requirements, including new obligations for online marketplaces. As well as the requirement to report suspicious transactions, economic operators supplying any reportable substances must now demonstrate that its personnel are aware of which of its products contain listed substances and are instructed on their obligations. Similarly, Border Force are working at pace alongside police colleagues to introduce measures to prevent any similar tragedies occurring. This includes development of specific national guidance for managing suspicious items which is currently lacking and improved sharing of information with police forces, and other relevant agencies where required, to safeguard vulnerable individuals to the full extent possible within the limits of its existing powers. This work is complex and, whilst underway, frontline Border Force staff who may encounter these consignments are actively being reminded of the steps they need to take with additional support available on a case- by-case basis. Border Force, on whom the Regulation 28 Notice is focused, has no control over the extent of the powers granted to it by primary or secondary legislation but is working at pace with Home Office policy leads to understand how it can help to prevent similar tragedies occurring. Furthermore, Border Force will however engage with police and legal colleagues to consider whether powers can be invoked on behalf of police where other relevant offences may apply. For example: • Suicide Act 1961 – section 2 “encouraging or assisting the suicide or attempted suicide of another person” which applies when; o there is sufficient evidence that the seller or exporter of the goods sold the as a means to assist or encourage suicide; or o the consignment includes a “suicide pack” e.g. anti-sickness pills, sedatives etc. 2 A4 By the nature of the importation in Dr Shaw’s case, this particular offence would likely have occurred overseas and therefore outside of the jurisdiction of domestic law. There may though be other cases going forward where, depending on the precise circumstances, the police could reasonably conclude that this offence may have been committed, thereby permitting seizure of the by Border Force or other agencies. • Online Security Act, which will place duties on online services hosting user generated content to assess and mitigate the risks of illegal content that encourages or assists suicide may offer further opportunities. There is also a new offence making communications, which encourage or assist self-harm, illegal regardless of whether or not victims go on to injure themselves which came into force on 31 January 2024. Those convicted face up to 5 years in prison. As above, where an offence is identified, seizure under S.19 PACE may apply. Responsibility for the regulation of substances under the Poisons Act falls within the remit of the Home Office, however the policy objective for this legislation and associated regulations relates to counter-terrorism risk reduction aims rather than health considerations and as such has not been regulated. is also imported for legitimate purposes such as food preservation. In addition, as this Act criminalises both the seller and the buyer, which also presents difficulties around issues such as suicide, self harm or substance abuse. Suicide is treated as a public health issue and is led by the Department of Health and Social Care (DHSC). My officials will therefore engage across government to highlight the issue. I have also written to the Health Secretary to ask that they consider this issue as part of the Suicide Prevention Strategy. I would like to reassure you that this is an important issue for Border Force and the Home Office and we will continue to work to ensure our front line officers understand presents. I will instruct my officials to work across the risks that government where other Departments may need to take action. We will also go further than focusing solely on , as whilst this was the substance used by Dr Shaw and the focus of your report, we recognise that future policy may need to also address threats presented by other substances as they emerge.” Yours sincerely, Home Secretary 3 A5
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