Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0346, written 9 Jul 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Jul 2025 |
|---|---|
| Reference | 2025-0346 |
| Deceased | Andrew Kenward |
| Coroner | Anna Loxton |
| Coroner area | Surrey |
| Category | Alcohol, drug and medication related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE SURREY CORONER’S COURT
IN THE MATTER OF:
__________________________________________________________
The Inquest Touching the Death of Andrew Nathan Paul KENWARD
A Regulation 28 Report – Action to Prevent Future Deaths
__________________________________________________________
THIS REPORT IS BEING SENT TO:
1.
2.
Social Care
, Home Secretary
, Secretary of State for Health and
1 CORONER
Ms Anna Loxton, HM Assistant Coroner for Surrey
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7(1) of Schedule 5 to The Coroners
and Justice Act 2009.
3
INVESTIGATION and INQUEST
Andrew Nathan Paul Kenward died on 24th October 2022, aged 30. His
inquest was opened on 2nd May 2023. A summary inquest took place on
17th June 2025. I recorded a conclusion of Suicide.
I found the medical cause of death to be:
1a.
Toxicity
4 CIRCUMSTANCES OF THE DEATH
Early on the morning of 24th October 2022, Andrew Kenward was found
deceased in his car parked on a road in Sunbury on Thames, Surrey, from
an overdose of a poisonous substance, namely
. Mr
Kenward had previously expressed an intention to end his life to a friend
and an undated note was found in his bedroom drawer expressing his
regret and love for his Family, but that he felt unable to continue living.
were also found in Mr Kenward’s
Two packets of
bedroom, both stated to contain 50g
. One of these was
sealed and weighed 51.45g. The second was resealable and weighed
RT4563
1
49.48g. The states purity was “99.999% pure”. The source of these packets
remains under Police investigation.
5 CORONER’S CONCERNS
A lethal dose of
able to procure a total of 1kg of
can be as small as 1g. Mr Kenward was
at 99.999% purity.
Coroners including myself have previously raised in Prevention of
Future Death reports that there is no central monitoring system which is
able to record incidents of sodium nitrite poisoning, although the use of
sodium nitrite for self-harm is increasing.
and
are reportable substances under the
Poisons Act 1972. The only obligation under this legislation is that
domestic sellers must report reasonable grounds for believing
transactions are suspicious. Whilst the source of this particular
is not currently known, there are no restrictions on the import of
from abroad.
or
Whilst these substances have legitimate uses, including meat
preservation, there does not appear to have been consideration as to
whether the purity can be diluted, or any other measures taken, to reduce
the risk posed by the quantities in which these substances are currently
sold, against the risk to life that they can pose.
The MATTERS OF CONCERN are:
-
-
-
can be purchased domestically with no
restrictions save a duty on sellers to report suspicious transactions;
can be purchased from abroad and imported
to Great Britain with no restrictions;
is sold at levels of purity (99%) and in quantities
which represent significant risk to life (up to 1000 fatal doses for
1kg sale), whether by self-harm or terrorist use;
- The quantities and purity in which
are sold
do not appear to be those required for their legitimate use, for
example in meat preservation;
of
It does not
there
outside the
regulating/monitoring the use of
limited provisions of the Poisons Act 1972, and it is not clear which
Government department would be responsible for this.
consideration
appear
any
is
-
RT4563
2
Consideration should be given as to whether any steps can be taken to
address the above concerns.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I
believe that the people listed in paragraph one above have the power to
take such action.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of its date; I
may extend that period on request.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for such action. Otherwise you must
explain why no action is proposed.
8 COPIES
I have sent a copy of this report to the following:
1. See names in paragraph 1 above
2.
3. The Chief Coroner
In addition to this report, I am under a duty to send the Chief Coroner a
copy of your response.
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 at the time of your response, about the release or
the publication of your response by the Chief Coroner.
Signed:
ANNA LOXTON
DATED this 9th day of July 2025
RT4563
3
2 responses 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.
Parliamentary Under-Secretary of State for Patient Safety, Women’s Health and Mental Health 39 Victoria Street London SW1H 0EU 22nd October 2025 HM Coroner Anna Loxton HM Coroner’s Court, Station Approach, Woking GU22 7AP Dear Ms Loxton, Thank you for the Regulation 28 report of 9th July 2025 sent to the Secretary of State / the Department of Health and Social Care about the death of Andrew Nathan Paul Kenward. I am replying as the Minister with responsibility for Mental Health. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Kenward death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. The report raises concerns over the fact that Mr Kenward was able to buy large amounts of sodium nitrite. Officials within the Department of Health and Social Care have considered these concerns and concluded that the responsibility for these concerns sits within another organisation. I understand that this report was also made to the Home Office, and I hope that their response will be helpful. Thank you for bringing these concerns to my attention. Yours sincerely,
Security Minister
2 Marsham Street
London SW1P 4DF
www.homeoffice.gov.uk
Ms Anna Loxton
HM Assistant Cooner for Surrey
HM Coroner’s Court
Station Approach
Woking
GU22 7AP
By email: coronersoffice@surreycoroner.gov.uk
18th August 2025
Dear Ms Loxton,
ANDREW NATHAN PAUL KENWARD REGULATION 28 REPORT TO
PREVENT FUTURE DEATHS
Thank you for the Regulation 28 report, dated 9 July 2025, sent to the Home
Secretary following the inquest into the death of Andrew Kenward, who
tragically died on 24th October 2022. I am responding on behalf of the Home
Secretary, as the Security Minister.
Firstly, I would like to extend my sincere condolences to Mr Kenward’s family
and loved ones. We are very grateful for your careful consideration of the risks
posed by the substance mentioned in your report, and for raising these
important matters of public safety.
You have raised a number of concerns, many of which echo those previously
highlighted in your report following the inquest into the death of Hannah
Aitken. I would like to assure you that the Government continues to take these
issues very seriously and is actively working across departments to address
them.
The substance in question is currently classified as a reportable substance
under the Poisons Act 1972. While this requires GB-based sellers to report
suspicious transactions, we acknowledge that this obligation does not apply to
sellers based overseas. My officials are currently carrying out research into
the availability of the substance in question, both domestically and
internationally.
The Home Office supports the Department for Health and Social Care (DHSC)
in delivering the Suicide Prevention Strategy for England (2023–2028), which
1
includes targeted action on emerging methods of suicide. In recent months,
my officials have been working with the Department of Health and Social Care
(DHSC) and other departments to assess the feasibility of additional
regulatory and non-regulatory levers for the substance in question. A cross-
government workshop took place in June to explore these options. Further
meetings will shortly be held between senior officials to agree
recommendations for a coordinated government response.
In the meantime, the Home Office continues to engage with industry to
promote responsible sales practices. 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.
Moreover, to target potentially harmful acquisitions of this substance from
overseas merchants, last year Border Force issued guidance to its officers
about the control actions they must take, within existing legal provisions, 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.
Thank you again for your report and for your continued efforts to prevent
future deaths.
Yours sincerely,
Security Minister
2
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.