Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0544, written 30 Jul 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Jul 2024 |
|---|---|
| Reference | 2024-0544 |
| Deceased | Bethany Langton |
| Coroner | Laurinda Bower |
| Coroner area | Nottingham City and Nottinghamshire |
| Category | Suicide (from 2015) |
| Organisation named | Nottinghamshire Healthcare NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Department for Health and Social Care, National Suicide Prevention Strategy Advisory Group 2 Department for Science, Innovation and Technology 1 CORONER I am Miss Laurinda Bower, HM Area Coroner for the coroner area of Nottingham City and Nottinghamshire 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 11 May 2023, I opened an inquest touching the death of Bethany Paige Langton, aged 22 years. The inquest concluded on 8 July 2024. The conclusion of the inquest was that Beth had died by suicide. 4 CIRCUMSTANCES OF THE DEATH On 18 February 2023, Bethany Paige Langton was discovered deceased inside her bedroom at Oakwell House, on Church Lane, in Hayton, Retford, Nottinghamshire, having died following the ingestion of sodium nitrite which she had sourced online in January 2023. Beth had used the internet to research how to die using sodium nitrite and followed the advice she had found online. Beth deliberately ingested the substance with the intention of bringing about her death. Beth was vulnerable having been diagnosed with complex mental health diagnoses. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could 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. The continued ease of availability of Sodium Nitrite to members of the public. The substance is lethal when ingested, even in relatively small quantities. It’s use in suicide is increasing. The substance is readily available to purchase online without the need for any explanation of the purchaser’s intended use for the substance, or an end user certificate/licence to track where it is being distributed. 2. Lack of awareness amongst businesses that the substance is being obtained for this purpose. Regulation 28 – After Inquest Document Template Updated 30/07/2021 The company who supplied Beth with the sodium nitrite used in her death, had no idea that the substance might be sourced by individuals for this purpose. Had they have been aware of the risk, they would likely have improved systems for investigating the intended use, or would have stopped offering the item for sale to individuals, as they have now done so. 3. Beth used the internet to research how to source and use sodium nitrite to bring about her death. She followed that guidance meticulously. That same guidance was still readily available on the internet at the time of her inquest, although I believe it might now have been removed. What system is in place to ensure that such websites are detected promptly and made unavailable to the public in a timely fashion? 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 Thursday 26 September 2024. 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 Beth’s Family Techmate Ltd Creative Care Ltd Clinical Psychologist Gillian Merrill GP Dr Ilet Nottinghamshire Healthcare NHS Foundation Trust Nottinghamshire County Council NSVSS CQC **This report is shared with the recipients in unredacted form, but any published version of this report shall be redacted to avoid the risk of becoming a source of information available on the internet about this substance** I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 Dated: 30 July 2024 Regulation 28 – After Inquest Document Template Updated 30/07/2021 Miss Laurinda Bower HM Area Coroner Nottingham City and Nottinghamshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Parliamentary Under-Secretary of State for Patient Safety, Women’s Health and Mental Health From 39 Victoria Street London SW1H 0EU 23 September 2024 Our ref: Miss Laurinda Bower Area Coroner HM Coroner’s Service The Council House Old Mkt Square Nottingham NG1 2DT By email: Dear Miss Bower, Thank you for the Regulation 28 report of 30 July 2024 sent to the Department of Health and Social Care about the death of Bethany Paige Langton. I am replying as the Minister with responsibility for Patient Safety and Mental Health. Firstly, I would like to say how saddened I was to read of the circumstances of Bethany’s death and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. The report raises concerns over the continued ease of availability of the substance to members of the public, lack of awareness amongst businesses that the substance is being obtained for this purpose, and the availability of guidance to use the substance to bring about death. In preparing this response, my officials have made enquiries with NHS England (NHSE), Department for Science, Innovation and Technology (DSIT) and Home Office (HO) to ensure we adequately address your concerns. The Government has taken steps to reduce access to and awareness of this substance and therefore reduce the risks of further deaths by suicide. The Department of Health and Social Care leads an emerging methods working group to prevent awareness and access to substances such as this one. The working group involves representatives from the voluntary, community and social enterprises sector, police, academics, and the NHS, as well as government departments including the Home Office and the Department for Science, Innovation and Technology. The group ensures rapid targeted actions to collectively reduce public access to emerging methods, including this particular substance. This includes reducing the sale and importation of methods where appropriate as well as reducing references to, and limiting awareness of, them. The group has worked with business, including online suppliers and manufacturers of the substance, to significantly reduce access. We have also worked with major online suppliers to remove it from sale to individuals in its pure form. We continue to work operationally with our broader partners, including Border Force and the police on interventions to reduce access to this specific substance for the purpose of suicide. These actions are kept under operational review. I would also like to assure you that the Government has also taken action to address the prevalence of harmful suicide and self-harm content online such as the websites you refer to. For example, as you will be aware, the Online Safety Act, when fully in force, will require all services in scope to rapidly remove regulated content that meets the criminal threshold once they become aware of it. This includes illegal suicide and self-harm content. Under the Act, search services also have targeted duties that require them to minimise the risk of users encountering illegal search content, such as those found on this specific website. There is also a requirement for search services to take or use, where proportionate, user support measures. The regulator now responsible for online safety, Ofcom, will recommend measures that search services can put in place to achieve these objectives. These could include removing results for sites that are known to host illegal suicide and self-harm content, as well as signposting users towards sources of support. The Act provides Ofcom with a robust suite of enforcement powers, including business disruptions measures and significant fines for use in the case of non-compliance. The Government has also worked with internet service providers, tech companies and social media platforms, as well as expert advisors such as the Samaritans, to tackle harmful pro- suicide forums. In addition, in September 2023 the multi-sector and cross-government suicide prevention strategy for England was published. The five-year strategy set out over 130 actions aimed at reducing the rates of suicide in England and work continues to implement these actions. As part of our mission to build an NHS fit for the future, the Government has committed to tackling suicide as one of this country’s biggest killers and recruiting 8,500 new mental health workers who will be specially trained to support people at risk from suicide. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, PARLIAMENTARY UNDER-SECRETARY OF STATE FOR PATIENT SAFETY, WOMEN’S HEALTH AND MENTAL HEALTH
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