Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0256, 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 | 2025-0256 |
| Deceased | Kelly Walsh |
| 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. THIS REPORT IS BEING SENT TO: 1 Secretary of State for the Home Department Home Office 2 Masham Street LONDON SW1P 4DF CORONER Iam 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 08 March 2021 I commenced an investigation into the death of Kelly Michelle Walsh aged 45. The investigation concluded at the end of the inquest on 07 February 2023. The medical cause of death was determined to be: 1a EE toxicity I returned a short form conclusion that Kelly Michelle Walsh died as the reuslt 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. CIRCUMSTANCES OF THE DEATH On the 27th of February 2021 the deceased was discovered in a collapsed and unresponsive condition within her residence, where attending paramedics confirmed her as dead and beyond attempted resuscitation. Attending police confirmed an absence of suspicious circumstances and recovered no note or other direct expression of her intent. The deceased’s post-mortem samples revealed the presence of recently ingested and fatally toxic levels i eco which metabolised quantities a noted to be present. The deceased had recently sourced and acquired a quantity of from an internet-based supptier in Lithuania. Although the precise amount ordered and time this was done was not clear, from packaging at the scene it was established that it had been delivered recently to her usual address in Atherton that, in fact, she had not been occupying for several weeks prior to her death. Regulation 28 — After Inquest Document Template Updated 30/07/2021 The deceased had a medical history that included episodic low mood and anxiety. Historically, she had been considered to have suffered from symptomologies of Post Traumatic Stress Disorder, Bi-Polar Affective Disorder, and phases of emotional dysregulation with previous episodes of attempted self-harm. The evidence established that despite being considered to possess capacity, from October 2020 she had recently entered a phase of mental health deterioration with psychotic lapses, including delusional and disordered thoughts and actions. Her mental health condition had previously been treated actively by way of inpatient treatment and at the time of her death, her enduring significant risk of self-harm was being managed conservatively in the community. The actions that brought about her death were both deliberate and intentional, precipitated by multi-factorial stressors that included her enduring mental ill-health, financial concern and worry, recent peripatetic living arrangements away from her home and family, and matters arising from issues connected to elements of dysfunction from within a new domestic relationship. 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 is 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 A 2024) does not give specific guidance or suggested training to sellers, particularly imei. cs 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 moe 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 JM 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 were 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 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 Regulation 28 — After Inquest Document Template Updated 30/07/2021 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. 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 Kelly Michelle Walsh 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 T 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. 9 | Dated: 23 May 2025 Mr Timothy W Brennand HM Senior Coroner for Manchester West 4 Regulation 28 — After Inquest Document Template Updated 30/07/2021
See every Prevention of Future Deaths report matching Alcohol, drug and medication related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.