Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0255, 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 | 2025-0255 |
| Deceased | Chantelle Williams |
| Coroner | Timothy Brennand |
| Coroner area | Manchester (West) |
| Category | Alcohol, drug and medication related deaths · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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: ree ESEENTITA Secretary of State for the Home Department Home Office 2 Masham Street LONDON SW1P 4DF CORONER I am 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 S, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. _—$__—__| INVESTIGATION and INQUEST An Investigation into the death commenced on the 8th of Janaruay 2021 and an Inquest heard before me on the 2nd of December 2022 that concluded the Investigation. The medical cause of death was determined to be: I returned a narrative conclusion that Chantelle Williams died as the consequence an unknown quantity of recently self-administered [BM in circumstances where her intentions remain unclear. 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. CIRCUMSTANCES OF THE DEATH The deceased had a complex medical history that included previously diagnosed Bi-Polar Affective Disorder, Obsessive-Compulsive Disorder, Emotional Unstable Personality Disorder, Post Traumatic Stress Disorder, Schizoaffective Disorder and recently had been diagnosed to be suffering from Autistic Spectrum Disorder. She had a long history of treatment and care by her local Mental Health Trust that had included phases of both conservative community-based treatment and intensive crisis resolution home based treatment with 8 previous phases of both voluntary and involuntary hospital in-patient treatment and care. Her presentations had included enduring self-harming thoughts and actions with persistent suicidal ideation, previous overdose, impulsivity and emotional dysregulation, and auditory, visual and olfactory hallucination with pseudo-hallucinations within psychotic relapse phases that were diagnosed to be both trauma-induced and associated as a manifestation of her Regulation 28 — After Inquest Document Template Updated 30/07/2021 obsessive-compulsive disorder. The deceased had been in receipt of regular depot anti-psychotic medication. Following her acquiring a quantity of EM from an internet-based source, she had deliberately ingested a significant, but non-fatal dose on the basis of her using this substance as a form of self-harm in October 2019 culminating in her voluntary informal admission to the Keats Ward of the Meadowbrook Unit of Salford Royal Hospital, Stott Lane, Salford on the 26th of November 2019 where she received ongoing active care, supervision, treatment and monitoring. Had the deceased sought to be discharged or attempted to leave without clinical approval, it is likely that she would have been detained pursuant to the provisions of the Mental Health Act 1983 because of her assessed high risk of self-harm. In February 2020, the deceased had acquired a further quantity of EE whilst on ward and self-ingested a small quantity by reason of an act of self-harm, informing healthcare staff of her actions resulting in medical intervention. A multidisciplinary team review meeting interpreted that she was using such overdoses as a method of communicating her ongoing distress. Healthcare staff were aware of the deceased’s ongoing possession of MM and the high risk of self-harm with significant risk of deliberate or inadvertent overdose and her presumed or known possession of HER vas managed conservatively by reason of the deceased's status as a voluntary inpatient who had been continually assessed to have capacity. On the 29th of May 2020 at approximately 6.45am the deceased was observed in her room on Keats Ward in a collapsed, unresponsive and cyanosed condition. She was being observed hourly and had last been seen alive at about 6am. An immediate ‘crash call’ was made but she failed to respond to attempted resuscitation and was verified as dead at 7.20am that morning. Post-mortem samples from the deceased revealed the presence of fatally toxic levels of both 2 (likely from a single batch of MY the deceased had previously sourced, retained and hidden. The evidence does not establish the precise quantity or time she ingested the HR bt was analysed to be at levels that would rapidly, within minutes, precipitate unconsciousness, hypoxia and cardio-respiratory failure. The deceased had, incidentally, been properly prescribed promethazine - a sedating antihistamine to assist her sleep, that would also have produced an antiemetic effect. Police recovered no note or evidence of her intentions and were able to establish no suspicious circumstances or third-party involvement. 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. ee i a 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 nn acquired by members of | the public, particularly over ‘online marketplaces’ in circumstances of the purchase on a ‘one off’ Regulation 28 — After Inquest Document Template Updated 30/07/2021 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 SOO grams of less of [EEE to 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 Ee 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. 3. The potice 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 and abroad. | LONDON 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. ls | corres and PUBLICATION 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. I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1. The family of Chantelle Williams 2. HHJ Alexia Durran - The Chief Coroner of England and Wales Chief Coroner’s Office 11" Floor, Thomas More Building Royal Courts of Justice Strand Regulation 28 — After Inquest Document Template Updated 30/07/2021 I have also sent it to Greater Manchester Police Greater Manchester Mental Health 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: 234 May 2025 CE L_ Mr Timothy W Brennand HM Senior Coroner for Manchester West 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.
Dan Jarvis MBE MP
Security Minister
2 Marsham Street
London SW1P 4DF
www.gov.uk/home-office
Timothy W Brennand
HM Coroner’s Court and Office for Manchester West
Paderborn House
Howell Croft North
Bolton
BL1 1QY
4 March 2026
Dear Mr Brennand,
Thank you for your Regulation 28 reports sent to the Home Secretary following the tragic
deaths of William James Armstrong, Shaun Michael Bass, Mathew Anthony Price, Kelly
Michelle Walsh, Chantelle Williams, Samuel David Dickenson and Matthew Joseph
O'Reilly.
I am responding on behalf of the Home Secretary, in my capacity as the Minister of State
responsible for the Poisons Act. I would firstly like to apologise for the delay in responding.
Due to an administrative error, these reports were only recently received by the
department. I would also like to extend my deepest condolences to their families and thank
you for sharing the concerns raised in your reports, which I have carefully noted. I am
grateful to you for bringing these matters to my attention.
I acknowledge the issues you have raised, specifically around guidance and training for
suppliers and concerns regarding online suicide forums. These important issues were
addressed in my response to the PFD report following the inquest into the tragic death of
Andrew Brown, sent to you on 22 July 2025. To assist I have enclosed a summary of that
letter setting out Government's response on these matters (Annex A). Further to this
summary, I wish to set out the action being progressed across Government and clarify the
Home Office’s role and the steps taken to date.
The Department for Health and Social Care (DHSC) published the cross-
Government Suicide Prevention Strategy for England (2023-2028) in September
2023. The Home office supports DHSC in delivering this strategy, including
by staking targeted action to address emerging methods of suicide.
DHSC convene a Concerning Methods Working Group (CMWG), which brings together a
wide range of expertise from other government departments – including the Home
Office – alongside academics, voluntary sector organisations, law
enforcement, the NHS and coroner representatives. The Group’s purpose is to identify,
limit awareness of and reduce access to emerging methods of suicide.
This reflects the government’s commitment to a responsive and adaptive approach,
ensuring responses are informed by the latest intelligence and trends. Through this
forum, stakeholders have been examining the current understanding of the use sodium
nitrite and sodium nitrate in suicides.
Sodium nitrite is subject to several legislative regimes, including REACH
and food safety legislation. It is also a reportable poison under Part 4 of Schedule 1A of
the Poisons Act 1972. This means it may be sold to the public, but retailers must
report suspicious transactions to the Home Office where they have grounds to suspect
illicit use.
The Poisons Act supports the aims of the Government’s Counter Terrorism Strategy,
CONTEST, by enabling controls on chemicals and poisons that may be used to cause
harm, while ensuring legitimate access for lawful uses. The legislation applies
only to Great Britain (i.e. England, Scotland, and Wales), and there is no obligation for
retailers based outside this jurisdiction to report suspicious transactions.
The Homeland Security Group oversee the Poisons Act for counter-terrorism
purposes and works closely with other government departments in recognition that the
legislation may also support wider public safety issues, including suicide prevention. My
officials are working collaboratively with DHSC to assess whether, and how, the Poisons
Act could play a meaningful role in reducing harm in this context. More generally, the
Home Office keeps legislation under regular review to ensure it remains proportionate,
evidence-based, and aligned with national security and public safety objectives.
While sodium nitrite remains widely used for legitimate purposes (e.g., food curing,
industrial applications), retailers in Great Britain are legally obliged to report suspicious
transactions under the Poisons Act 1972. Border Force officers have been issued
guidance on identifying and intercepting consignments suspected for self-harm use. The
Home Office also engages with online platforms to encourage voluntary removal of listings
for high purity sodium nitrite.
To answer your questions about further regulation for sodium nitrite, as noted above,
DHSC and Home Office are working with stakeholders to consider whether additional
regulation would be effective and proportionate, and if so, which body would be best
placed to take forward any such work.
Adding sodium nitrite as a regulated poison under Part 2 of Schedule 1A of the Poisons
Act 1972 would make it a criminal offence for a retailer to supply it to a member of the
public without a Home Office licence; and a criminal offence for a member of the public to
import, acquire, possess or use it without a licence. However, this could impose burdens
on businesses and consumers who currently use it lawfully. Evidence also indicates that
most harmful purchases originate from overseas suppliers, which fall outside UK
legislative control. Making sodium nitrite a regulated poison under the Poisons Act 1972
would also criminalise the buyer. These points are actively being considered in the
conversations between departments.
Finally, I understand the troubling concerns you have raised about the pro-suicide forums.
DSIT, as the department responsible for the Online Safety Act, is committed to working
with Ofcom and bereaved families. This partnership aims to ensure the Act protects all
users from illegal suicide and self
that does not meet the criminal threshold.
harm content and shields children from harmful material
‑
Whilst the introduction of the Online Safety Act marked an important first step toward
securing safer online environments, the Government recognises the need to keep the
legislation under review and is committed to identifying where further strengthening may
be required. Since being appointed, DSIT’s Secretary of State, Liz Kendall, has ensured
there are stronger protections for vulnerable users by amending the Act to make
encouraging self-harm a priority offence. This triggers the strongest possible legal
protections, requiring in-scope services to proactively prevent all users from being
exposed to this content, as well as minimising the length of time for which such content is
present.
I hope this explanation is helpful in setting out the scope of the Home Office’s
responsibilities and the collaborative work underway across government. Preventing
access to harmful substances is a priority I take extremely seriously, and the Home
Office remains absolutely committed to supporting DHSC, coroners and law enforcement
partners in reducing the risks associated with sodium nitrite.
Thank you again for sharing these reports. I have asked my officials to continue
considering further measures, legislative and nonlegislative, in light of emerging evidence
and trends.
Yours sincerely,
Security Minister
Cabinet Office and Home Office
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