Hannah Aitken

From 

Parliamentary Under-Secretary of State for    
Patient Safety, Women’s Health and Mental Health  

39 Victoria Street   
London  SW1H 0EU   

15 January 2025  

Our ref: 

Ms Anna Loxton   
HM Coroner’s Court  
Station Approach  
Woking  
GU22 7AP  

By email: 

Dear Ms Loxton,   

Thank you for the Regulation 28 report of 14 November 2024 sent to the Secretary of State 
for Health and  Social Care  about  the death of  Hannah  Mary Aitken.  I  am  replying  as the 
Minister with responsibility for Patient Safety, Women’s Health and Mental Health.   

Firstly, I would like to say how saddened I was to read of the circumstances of Hannah’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. Thank you also for the additional time provided to the Department to respond 
to the concerns raised in your report.  

Your report raises concerns over the continued ease of availability of the substance involved 
in this case (which I will not mention by name) to members of the public.   

It  may  first help  to  clarify  the  Department’s  role  in  suicide  prevention. As  lead  for  suicide 
prevention  policy,  the  Department’s  role  is  to  coordinate  activity  across  government  and 
other  agencies  to  ensure  effective  and  cohesive  action  is  being  taken  in  the  right  areas. 
However, suicide prevention is a cross-Government issue and given its complexity, specific 
actions  and  mechanisms  are  led  by  a  wide  range  of  departments  and  organisations.   To 
support this coordination, DHSC published the Suicide Prevention Strategy for England in 
2023, setting out priority areas for action to support joint working. The five-year strategy set 
out actions aimed at reducing the rates of suicide in England, and work continues to deliver 
effective suicide prevention initiatives.   

On  methods of  suicide  specifically,  Government  departments  have  taken  steps  to  reduce 
access to, and awareness of, this substance. DHSC leads a Concerning Methods Working 
Group to raise awareness of and tackle access to substances such as this one. The working 
group involves representatives from the voluntary, community and social enterprise sector, 
police, academics and the NHS, as well as Government departments including Department 
of  Science,  Innovation  and  Technology  and  the  Home  Office.    The  group  develops  and 
delivers rapid targeted  actions  to  collectively  reduce  public  access  to  emerging  methods, 
including this one. Over 30 of the actions identified and implemented by the group have been 
to tackle this substance specifically.    

  
    
  
  
  
  
  
  
  
  
  
 The group has worked with businesses, including online suppliers and manufacturers of the 
substance,  to  reduce  people’s  ability  to  purchase  it  for  non-legitimate  purposes  including 
suicide,  and  to  raise  awareness  around  safeguarding  concerns  with  businesses  where 
required.  Government  departments  have  also  previously  worked  with  manufacturers  to 
reduce the lethality of the substance if ingested.  This included work with online platforms to 
remove it from sale to individuals in its pure form. The group continues to work operationally 
with a range of organisations, and we are actively considering opportunities to work with the 
Border Force, using existing legal provisions, to help detect packages at the border which 
may  be  linked  to  vulnerable  individuals and  intended for suicide. The group’s  actions are 
kept under review.        

On the issue of further regulation, the Department is working closely with the Home Office 
to  convene  Government  departments  and  agencies  to  identify  whether  regulation  is 
appropriate and would achieve the intended aim, and if so which body is best placed to take 
forward any reviews into this.   

You also raised the issue of monitoring. The Department monitors trends of this substance 
and other concerning methods as part of the working group. We have approaches in place 
to  collect  intelligence  from a  wide  range  of  sources.  We  use  Office  for National Statistics 
data,  and  we  are  exploring  how  to  make  better  use  of  national near  real  time  suspected 
suicide surveillance data to make sure we can identify and respond to trends more quickly. 
Regional  Leads  within  the  Office  for  Health  Improvement  and  Disparities  also  pass  on 
information from local organisations to central teams for monitoring. Whilst we observed an 
increase in the number of suicides using this method a few years ago, we have not found 
concrete  evidence  that  the  numbers  have  increased  in  the  last  few  years,  and  since  the 
Concerning Methods Working Group was set up.   We are working alongside the National 
Police  Chiefs’  Council  to  bring  together  important  local  intelligence.  The  government  will 
obtain  near to  real-time  data  from  across  the  country on  deaths  by  suspected  suicide  by 
gender, age group and method. We will engage with NHS England and others to look for 
ways we can strengthen information and monitoring routes into and out of national teams to 
address the concerns raised in your report.     

More broadly, 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  the  8,500  new 
mental health workers we will be recruiting will be specially trained to support people at risk 
from suicide. Ultimately, it is our aim to help and support people as early as possible, so they 
don’t feel the need to turn to these types of substances to take their own life.   

I hope this response is helpful, alongside a separate response which I understand the Home 
Office will be providing. Thank you for bringing these important concerns to my attention.    

Yours sincerely,   

PARLIAMENTARY UNDER-SECRETARY OF STATE FOR  
PATIENT SAFETY, WOMEN’S HEALTH AND MENTAL HEALTH

Security Minister 

2 Marsham Street 
London SW1P 4DF 
www.gov.uk/home-office 

07 February 2025 

Ms Anna Loxton 
HM Assistant Coroner for Surrey 
HM Coroner’s Court 
Station Approach 
Woking 
GU22 7AP 

By email: 

Dear Ms Loxton, 

HANNAH MARY AITKEN REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

Thank you for the Regulation 28 report, dated 14 November 2024, sent to the Home 
Secretary following the inquest into the death of Hannah Mary Aitken, who tragically died 
on 14 September 2023. I am responding on behalf of the Home Secretary, in my capacity 
as the Security Minister.  

Firstly, I would like to offer my heartfelt condolences to Ms Aitken’s family and loved ones 
at this difficult time. My thoughts are with them as they continue to navigate their profound 
loss. 

Thank you for the additional time provided to the Department to respond to the concerns 
raised in your report, which I have carefully noted. I am very grateful to you for bringing 
these matters to my attention. 

Your report has raised several matters of concern, which are relevant to both the Home 
Office and Department of Health and Social Care, namely: 

•  The substance in question can be purchased domestically with no restrictions save 

a duty on sellers to report suspicious transactions; 

•  The substance in question can be purchased from abroad and imported to Great 

Britain with no restrictions;  

•  The substance in question is sold at levels of purity and in quantities which 
represent significant risk to life whether by self-harm or terrorist use;  

•  The quantities and purity in which the substance in question are sold do not appear 

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to be those required for their legitimate use;  
It does not appear there is any consideration of regulating/monitoring the use of the 
substance in question outside the limited provisions of the Poisons Act 1972, and it 
is not clear which Government department would be responsible for this.  

Your report also highlights that there have been several tragic cases where this material 
has been used in incidences of death by suicide. Please note, following another tragic 

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 incidence of death following ingestion of the same substance, the Home Secretary has 
recently written to Ms Catherine McKenna, the Area Coroner for Greater Manchester 
North, detailing action the Home Office is taking on this issue. The letter emphasised the 
Government’s determination to ensure all reasonable steps to prevent further loss of life 
are taken.  

The Home Secretary has also written to the Secretary of State for Health and Social Care 
to ask that they give priority to this issue as part of their continued work on implementing 
the goals of the Suicide Prevention Strategy. This sets out actions aimed at reducing the 
rates of suicide in England. I have provided further detail below on joint action that is 
already underway. 

The substance described in your report is a “reportable” poison listed in Part 4 of Schedule 
1A of the Poisons Act. For the avoidance of doubt, this means that whilst it can be bought 
by members of the public, suspicious transactions need to be reported by retailers if there 
are questionable grounds for suspecting it is intended for any illicit use. The Poisons 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 their personnel are aware about which 
of their products contain listed substances, and are instructed on their obligations.  

As your report captures, the Home Office is aware of the issues relating to this substance. 
My officials have been undertaking work across Government to both reduce access to this 
substance, and raise awareness to suppliers of the dangers of this substance. To this end, 
the Homeland Security Group (HSG) have been working to improve retailer awareness of 
their legal obligation to report suspicious activity for regulated and reportable substances.  

Specifically, HSG have engaged with online platforms to encourage them to voluntarily 
remove the sale to individuals in its pure form. Government expertise in relation to 
substances of concern is also shared to inform retailer sales practices. This includes 
encouraging suppliers to use declaration of use forms for sales of such substances. This 
work will continue to ensure suppliers are meeting their requirements under the Poisons 
Act. Furthermore, if during the processing of suspicious activity reports a safeguarding 
concern is identified by Counter Terrorism Policing, consideration will be given to 
disseminating this intelligence to police forces to consider a welfare check.   

Similarly, Border Force has introduced guidance for its officers (operating within its existing 
legal provisions). This guidance provides instructions on the action they can take if they 
are in receipt of information, in any form or manner, that leads to a detection of goods at 
the border containing an item that may be intended to assist with suicide. This of course 
relies on Border Force working closely with police forces and other relevant agencies to 
safeguard vulnerable individuals to the full extent possible. This work is complex, and 
Border Force will continue to monitor its policies, exploring opportunities to improve its 
ability to take action. Where possible, Border Force will also continue to ensure that 
frontline staff who may encounter these items know what action to take, and are supported 
on a case-by-case basis when required. 

On the issue of further regulation, an aspect of the concern you have raised relates to 
individuals based in Great Britain, purchasing this substance from overseas retailers. As 
the Poisons Act only applies to Great Britain (i.e. England, Scotland, and Wales), there is 
no obligation for retailers based outside the specified jurisdiction to report transactions 
which they believe to be suspicious. The Department is seeking to address this, as well as 

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 the other issues raised in your report, such as the purity and quantities of the substance in 
question that are available for sale. My officials are working closely with the Department 
for Health and Social Care, convening relevant stakeholders to consider the potential 
benefits and proportionality of further regulation.  

Thank you for your report and for bringing these important matters to my attention. I hope 
that my response, alongside that of DHSC, has been able to address some of your 
concerns. I can assure you that the Home Office will continue to work in collaboration with 
relevant Departments and wider partners to take action in this area. 

Yours sincerely, 

Security Minister 

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