Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0258, 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 | 2025-0258 |
| Deceased | Andrew Brown |
| Coroner | Timothy Brennand |
| Coroner area | Manchester (West) |
| Category | Alcohol, drug and medication 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:
1
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 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
INVESTIGATION and INQUEST
On 14 August 2023 I commenced an investigation into the death of Andrew Alexander Roger BROWN
aged 45. The investigation concluded at the end of the inquest on 19 April 2024.
The medical cause of death was determined to be:
a
I returned a narrative conclusion that Andrew Alexander Roger BROWN died as the consequence of a
self-administered quantity off in circumstances where his 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 Apri! 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
Between January and June 2023, for reasons that could not be established, the deceased had
acquired and retained amongst his possessions at his residence, at least 3 consignments of the
registered poison EE obtained on the internet. He had a medical history that
included episodic mixed anxiety and depressive disorder, his relapse profile being linked to
dysfunctionality within his domestic matrimonial circumstances.
On the morning of the 9th of August 2023, the deceased was discovered by a family member,
collapsed and unresponsive within the bedroom of his residence at Po Wigan.
Paramedics attended promptly, establishing the deceased to be dead and beyond attempted
resuscitation.
Regulation 28 — After Inquest.
Document Template Updated 30/07/2021
A Greater Manchester Police investigation concluded there to be an absence of evidence that
supported a viable suggestion of there being third party involvement or suspicious circumstances in
the case. Beyond an ‘Advanced Decision to Refuse Treatment’ document found by paramedics on the
deceased’s bed, no direct evidence of the deceased’s intent was recovered or could be identified from
the evidence secured at the scene or otherwise.
A forensic post mortem examination established the sole cause of death to have been
HE oxicity, albeit the evidence could not establish either directly or by inference in what
quantity, at what time, in what circumstances and for what reason the deceased had self-
administered an amount of MY that could be presumed to have been dissolved in
liquid and thereafter ingested at his own hand. Of a number of possible inferences that could be
drawn as to his intentions, including his actions being influenced by illogical, strange and disordered
thinking in the context of emotional dysregulation arising from his personal circumstances and mental
health history, the more likely factor that motivated his actions was a manifestation of fleeting, ill-
considered, irrational self-harming ideation acted out as a means of displaying a desire for rescue and
help, the deceased naively failing to appreciate or understand the potential lethality of ingestion of
even a modest quantity of MM his death being an inadvertent and unintended
consequence of his deliberate actions.
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 untess 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 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 in” acquired 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 MMto 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
Regulation 28 — After inquest
Document Template Updated 30/07/2021
their life in circumstances where:
a. the vendors of the HE 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 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 Andrew Alexander Roger BROWN
2. HH) Alexia Durran - The Chief Coroner of England and Waies
Chief Coroner's Office
11" Floor, Thomas More Building
Royal Courts of Justice
Strand
LONDON
T have also sent it to
Greater Manchester Mental Health
Greater Manchester Police
Shevington Surgery
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.
Regulation 28 — After Inquest
Document Template Updated 30/07/2021
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: 23'4 May 2025
/
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.
OFFICIAL Mr Timothy Brennand HM Senior Coroner for Manchester West Coroner’s Office Greater Manchester West First Floor Padeborn House Howell Croft North Bolton BL1 1QY By email: Dear Mr Brennand, Security Minister 2 Marsham Street London SW1P 4DF www.gov.uk/home-office 22 July 2025 TIMOTHY W BRENNAND REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Thank you for the Regulation 28 report, dated 23 May 2025, that was sent to the Home Secretary following the inquest into the death of Andrew Brown, who tragically died on 9th August 2023. I am responding on behalf of the Home Secretary, in my capacity as the Minister of State for Security. I would like to offer my heartfelt condolences to Mr Brown’s family and loved ones – though almost two years have passed, I understand that the pain of such a profound loss endures. Thank you for sharing the concerns raised in your report, which I have carefully noted. I am 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: • There is no specific guidance or training for sellers of the substances in question, particularly over online marketplaces in circumstances of the purchase on a ‘one off’ basis for the means of self- harming. Additionally, current guidance does not specifically reference these substances as a concern. • Potentially suspicious sales of these substances are often evaluated as being for legitimate uses. • Vendors are often not aware of its potential for misuse, or that their details are being shared on suicide-related internet forums. • Members of the public are able to access websites hosted overseas that promote information on methods of suicide and information on how to source poisons that can bring about death. As your report highlights, there have been several tragic cases involving these substances. The substances involved in your report are “reportable” substances listed in Part 4 of Schedule 1A of the Poisons Act. This means they can be purchased by members of the public, but suspicious transactions must be reported by retailers if there are questionable grounds for suspecting it is intended for any illicit use. The aim of the legislation is to control chemicals and poisons that can be used to cause harm, while still allowing members of the general public and businesses with a legitimate need to access these substances to continue their activities. It falls under my portfolio as Security Minister as the legislation supports delivery of the Government’s counter-terrorism strategy, CONTEST. The Poisons Act was amended in October 2023 to strengthen controls and enhance our suspicious activity reporting requirements. This includes 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 of which of their products contain listed substances and are instructed on their obligations. Concerns about these substances have been raised through coroner’s reports and other correspondence. In response, the Home Office has been working with other government departments to limit access to these substances and raise awareness among suppliers about the risks of misuse. In a recent letter to , Assistant Coroner for Surrey, I outlined the Home Office’s response following another such incident. Since then, officials from the Home Office and the Department of Health and Social Care (DHSC), who manage the national Suicide Prevention Strategy, have been collaborating to assess policy options and coordinate a cross-government response. This response builds on the existing measures that are already in place. Responding to the issues your report raises in turn: • Guidance and assessment of suspicion: The substances in question are not routinely individually highlighted within government issued guidance in relation to their potential misuse for self-harm or suicide. This is to avoid bringing widespread attention to them. However, my officials have engaged with selected online platforms and retailers individually to encourage them to voluntarily remove the sale of these substances to members of the public in their pure form and be vigilant for the possibility of purchase for self-harm or suicide. For all substances within scope of the Poisons Act, the Homeland Security Group works to improve retailer awareness of their legal obligation to report suspicious activity and to inform retailer sales practices. For example, we encourage suppliers to use declaration of use forms for sales of potentially harmful substances. This work will continue to ensure suppliers are meeting their obligations 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. To target potentially harmful acquisitions from overseas merchants, Border Force has introduced new guidance for its officers. This guidance operates within existing legal provisions. It sets out the actions officers can take if they receive any form of information suggesting that goods at the border contain items intended to assist with suicide. This 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 act where possible and to ensure that frontline Border Force staff who may encounter these items know what action to take and are supported on a case-by-case basis when required. • Suicide-related online forums: 2 As your report highlights, we are aware of the existence of a number of websites, hosted overseas, which promote information about how to access poisons for the purposes of suicide. As of 17 March 2025, the illegal content duties in the Online Safety Act (OSA) came into effect, which is an important and positive step in addressing a range of online harms. Providers in scope of the OSA are legally required to implement measures to reduce the risks that their services are used for illegal offending and remove illegal content from their platforms where it does appear. This includes illegal content relating to the most serious and prevalent illegal content and activity such as terrorism, child sexual exploitation, inciting violence, and encouraging or assisting suicide. These measures are designed to create a safer online environment by ensuring robust systems and processes are in place to protect users from illegal content. The Online Safety Act applies to services even if the companies providing them are overseas, should they have links to the UK. This includes if the service has a significant number of UK users, if the UK is a target market, or if it is capable of being accessed by UK users and there is a material risk of significant harm to such users. Ofcom is the regulator for this regime. It has strong enforcement powers where providers fail to comply with their duties. Ofcom have launched several enforcement programmes to monitor compliance with the regime, including an investigation into a service linked to promoting suicide content1. The government is closely monitoring the implementation and effectiveness of the OSA and remains committed to strengthening our laws if it does not deliver the necessary protections to ensure a safer online environment. Thank you for bringing these important concerns to my attention. I hope that this response is helpful. Please be assured that the Home Office is actively working with relevant departments and partners to mitigate the dangers associated with these substances. Yours sincerely, Security Minister 1 Ofcom investigates online suicide forum - Ofcom: https://www.ofcom.org.uk/online-safety/illegal-and-harmful- content/ofcom-investigates-online-suicide-forum 3
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