Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0253, written 23 May 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 May 2025 |
|---|---|
| Reference | 2025-0253 |
| Deceased | Shaun Bass |
| Coroner | Timothy Brennand |
| Coroner area | Manchester (West) |
| Category | Alcohol, drug and medication related deaths · Mental Health related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. 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: | ecretary of State for the Home Department Home Office 2 Masham Street LONDON SW1P 4DF CORONER Tam Mr Timothy W Brennand, HM Senior Coroner for the coroner area of Manchester West. 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. } INVESTIGATION and INQUEST On 10 September 2020 I commenced an investigation into the death of Shaun Michael Bass aged 23. The investigation concluded at the end of the inquest on 11 August 2022. The medical cause of death was determined to be; I returned a short form conclusion that Shaun Michael Bass died as the result of suicide. Reporting restrictions were imposed in this case because of an ongoing criminal investigation in the United Kingdom, Europe and the United States of America, the case being one of a cluster of eight similar cases upon the Greater Manchester West jurisdiction. Reporting restrictions were lifted on the 19th of April 2024. This report is being published following updates from Greater Manchester Police and suicide prevention organisations received on the 14th of March 2025. 4 | CIRCUMSTANCES OF THE DEATH The deceased had a medical history that included persistent and enduring anxiety and depressive disorders that had required previous inpatient phases of treatment and care but had recently been treated and managed conservatively in the community. On the 23rd of February 2020, the deceased was discovered collapsed and unresponsive in his residence ; Ea Bolton having ingested a significant quantity of that he had acquired earlier in the month from an internet-based company licensed to sell reportable poisons. He was verified as dead and beyond further attempted resuscitation by attending paramedics. From within the premises, police recovered a note of intent recently handwritten by the deceased and empty packaging labelled Ea - Extra Pure 99.9% 50g" - for meat curing” the deceased had sourced via accessing a website promoting and sanctioning self-harm by means of Regulation 28 — After Inquest. Document Template Updated 30/07/2021 sodium nitrite poisoning. Post-mortem samples were analysed and confirmed the deceased had recently ingested a significant and fatally toxic quantity of sodium nitrate/nitrite. The evidence established suboptimal elements in the mental healthcare and management of the deceased namely, a lack of continuity of personnel responsible for the deceased's care co-ordination, no mental health assessment review that was due to have taken place in November 2019, no adequate or immediate response to family concerns that had been communicated to health care professionals in January and February 2020. Whilst the consequence of the suboptimal healthcare in terms of bearing upon outcome cannot be evaluated, they represent a series of missed opportunities to record, discuss, review or adequately safeguard the deceased during a phase of deterioration in his mental heaith with the consequence that treating healthcare professionals failed to appreciate that the deceased was at an increased risk of self-harm. 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: (brief summary of matters of concern) 1. Es 2 reportable poison as well as a reportable explosives precursor within the terms, meaning and effect of Part 4 of Schedule 1A of the Poisons Act 1972 with the consequence that: a. The Poisons Act 1972 sets out the legal obligations in relation to the sale, purchase, and use of these chemicals for suppliers, professional users and members of the public. b. The published Guidance (commenced in 2014 and updated in August 2024) does not give specific guidance or suggested training to sellers, particularly ie cquired by members of the public, particularly over ‘online marketplaces’ in circumstances of the purchase on a ‘one off’ basis for the means of self-harming. c. Whilst there is a legal duty on persons selling this substance to report “suspicious” transactions within 24 hours to the Home Office, the purchase of small quantities is being presumed to be connected to the many legitimate uses of the substance (such as food preservation, fertilizer etc) rather than in fact, being evaluated as a member of the public seeking purchase of modest quantities used as their chosen means by which to end life. d. The current Home Office guidance and supporting video, leaflet and posters do not reference as a specific example of concern and focuses on the phenomenon of ‘malicious’ misuse and not deliberate misuse in the sense of suicide/self-harm. 2. The police investigation into one UK based source of supply revealed in 247 cases separate supplies of 500 grams of less of customers in the UK and Europe, police established that 85 of these individuals who were traceable had either died as the consequence of self-ingestion of the substance, or had purchased it with a view to having the means to use this method to end their life in circumstances where: a. the vendors of the [I vere not aware of this potential misuse of the substance. b. the small quantities being purchased had been incorrectly evaluated to be an increase in individuals pursuing recreational home-curing/food preservations as a hobby, being an artefact of ‘lockdown’ living following the COVID national pandemic emergency. c. Vendors were unaware that their website/details were being distributed as part of internet information platforms designed to aid, abet, assist or promote suicide methods. d. From the specific example of 247 supplies in a 12 month period, police established that 45 purchasers were confirmed as deceased (these deaths were in relation to supplies to UK customers Regulation 28 — After Inquest Document Template Updated 30/07/2021 and purchasers from abroad) and only 15 purchases were confirmed to have taken place for ligitimate purposes (meat curing etc.). 3. The police investigation revealed the ability of members of the public to access a number of websites, primarily created in the USA, Canada and Mexico that promoted information as to how to access: a. Poisons that could bring about death b. How, in what way and with with other necessary preparations (in particular -antiemetic medications) the poisons should be administered. c. Sourcing such poisons/chemicals/medications in the UK or abroad. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by May 16, 2025. 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1. The family of Shaun Michael Bass 2. HH) Alexia Durran - The Chief Coroner of England and Wales Chief Coroner’s Office 11" Floor, Thomas More Building Royal Courts of Justice Strand LONDON I have also sent it to Greater Manchester Police who may find it useful or of interest. 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. Dated: 23" May 2025 Regulation 28 — After Inquest Document Template Updated 30/07/2021 Mr Timothy W Brennand HM Senior Coroner for Manchester West Regulation 28 — After Inquest Document Template Updated 30/07/2021
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