Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0619, written 9 Oct 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 Oct 2025 |
|---|---|
| Reference | 2025-0619 |
| Deceased | Stella LeClaire |
| Coroner | Christopher Williams |
| Coroner area | Northamptonshire |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Secretary of State for Health and Social Care -
Secretary of State for the Home Department-
1
CORONER
I am Christopher Williams, Assistant Coroner, for the area of London Inner South.
2
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.
3
INVESTIGATION and INQUEST
On the 1/8/23 a coroner’s investigation was commenced into the death of Stella Elizabeth
LeClaire, formerly known as Mia Levy. The inquest was concluded on the 4/12/2025.
4
CIRCUMSTANCES OF THE DEATH
1. On the 28/7/23 at 16:46 pm Stella checked into a hotel in Tooley Street, Southwark.
Hotel electronic key records show that she did not leave the room after she checked
in. On the 30/7/23 she was discovered unresponsive by hotel staff at 13:45 pm and
was subsequently pronounced dead by the ambulance service at 14:56 pm.
2. A police investigation revealed she had sent a farewell email message, to her
partner in the United States, timed to be sent at 10:31 am on the 30/7/23,
expressing that she could not continue living with constant migraines and nausea
and that her health was getting worse. It had not been possible to access Stella’s
phone and laptop for logistical reasons, but her partner disclosed the email to the
police shortly after receiving it.
3.
analysed and found to contain
the
to her and the circumstances in which she obtained it.
in a container recovered from the room, was
. It is not known who supplied
4. A post-mortem identified the cause of death as 1(a)
toxicity. This finding
was inferred from circumstantial evidence by the post-mortem pathologist.
5. A routine toxicology screening report also detected
, an antiemetic,
which has been taken alongside
in other reported cases.
6. A further toxicology report from a specialist toxicology service, analysed a femoral
blood sample, taken at autopsy. This report confirmed the level of
extremely high and that it was ‘highly likely’ that this caused the death.
was
7. Stella had taken the
recorded a short form conclusion of “Suicide” in the Record of Inquest.
with the intention of ending her own life and I
1
5
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to a 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. –
1. During the course of the inquest I received information from the Toxicology service,
that serves my court, that the number of requests by coroners, in 6 coroner areas, for
analysis of blood samples for the presence of
2021.
, had increased since
2.
I am also aware that in the last 5 years prevention of future death reports have been
submitted from a number of other coroner areas. In broad terms the reasons for those
reports are concerns that the substance is sold
method.
suicides
advocating its use in
3. Although there was circumstantial evidence that Stella died from
toxicity, I was at pains to obtain a specialist toxicological analysis of a blood sample.
The reason for this was to ensure that if the supplier of the substance can be
identified in future the chances of successful prosecution would be improved by direct
evidence of the cause of death. I raise this in case the Chief Coroner may wish to
consider issuing guidance on whether blood toxicological analysis should be obtained
routinely in coroners’ investigations concerning
poisoning.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisation has the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 03/02/2026 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:
•
•
•
Stella’s father
Sister
I have also sent it to: The Metropolitan Police Service and Nadia Persaud Area Coroner
for East London, 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 other 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. She may send a copy of this report to any person who she 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.
2
9
9th December 2025
Christopher Williams
3
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.
Our ref: PFD – 25-12-09 - LeClaire
Christopher Williams
Assistant Coroner
Southwark Coroners Court
1 Tennis Street
London
SE1 1YD
Dear Mr Williams,
From Baroness Merron
Parliamentary Under-Secretary of State for
Women’s Health and Mental Health
39 Victoria Street
London
SW1H 0EU
25 March 2026
Thank you for the Regulation 28 report of 9 December 2025 sent to the Secretary of State for
Health and Social Care about the death of Stella Elizabeth LeClaire. I am replying as the
Minister with responsibility for Women’s Health and Mental Health.
Firstly, I would like to say how saddened I was to read of the circumstances of Stella’s death
and I offer my sincere condolences to their family and loved ones. The circumstances your
report describes are very concerning and I am grateful to you for bringing these matters to
my attention. Thank you for the additional time provided to the department to provide a
response to the concerns raised in the report.
The report raises concerns over a number of issues which you believe may pose a risk of
further deaths if not addressed. You note that coroners in several areas have increasingly
needed to request specialist laboratory analysis to detect the presence of a particular
substance in blood samples, reflecting wider patterns seen since 2021. You also highlight the
continued online availability of this substance, including instances where websites advocate
its use in suicides. In addition, you emphasise the importance of obtaining specialist
toxicological testing in this case to help establish the cause of death and suggest that the
Chief Coroner may wish to consider whether more consistent guidance on when such testing
should be sought would be beneficial for future investigations.
The Department recognises the importance of understanding emerging methods of suicide
and the need to coordinate activity across government to reduce the risks they pose. As part
of this work, we monitor concerning trends through the Concerning Methods Working Group,
which brings together representatives from across government, policing, academia, the NHS
and the voluntary sector. This group supports the rapid sharing of intelligence, including
patterns that may be reflected in requests made by coroners for toxicology analysis, with the
aim of enabling swift cross‑government action where needed. The Working Group also
includes representation from the coroner community, ensuring that learning from Prevention
of Future Deaths reports forms an important part of how emerging risks are identified and
addressed.
A significant part of the group’s work has focused on limiting public access to the substance
involved in this and other cases, and more than 30 targeted actions have been taken to
reduce opportunities to obtain it for non‑legitimate purposes. These include operational work
with online suppliers, platforms and manufacturers to raise safeguarding concerns, restrict
availability, and prevent its sale in particularly concerning ways, including on online forums.
Government departments have also worked with online platforms to reduce opportunities for
the substance to be purchased by individuals. We are also exploring opportunities to work
with Border Force, using existing legal provisions, to improve detection of packages that may
be linked to vulnerable individuals. The group monitors the effectiveness of these measures
and continues to consider future opportunities for action as new intelligence emerges.
You also raise the question of whether more consistent guidance on obtaining specialist
toxicology might support coroner investigations in these types of cases. As you will know,
decisions on issuing guidance rest with the Chief Coroner. Your report has been shared with
them, and the Department will continue to work closely with the Chief Coroner’s Office, which
is represented on the Concerning Methods Working Group, to ensure that learning from PFD
reports, intelligence from coroners, and suggestions for further action are fully considered
within existing responsibilities.
More broadly, as part of our mission to build an NHS fit for the future, the Government has
committed to tackling suicide as one of this country’s biggest killers. Ultimately, our aim is to
provide help and support as early as possible so that people do not feel the need to turn to
these types of substances to take their own life.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Yours sincerely,
BARONESS MERRON
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