Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0231, written 29 Apr 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Apr 2026 |
|---|---|
| Reference | 2026-0231 |
| Deceased | Alice Dearden |
| Coroner | Nicholas Rheinberg |
| Coroner area | Wiltshire and Swindon |
| Source | judiciary.uk record |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: eBay, 1 More London Place, London, SE1 2AF 1 CORONER I am Nicholas Rheinberg assistant coroner, for the coroner area of Wiltshire and Swindon 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 12th March 2020 an inquest was opened into into the death of Alice, Sarah, Dearden (Alice) aged 19. The investigation concluded at the end of the inquest on 28th April 2026. The conclusion of the inquest was that Alice died by suicide 4 CIRCUMSTANCES OF THE DEATH Alice suffered from mental health difficulties as a result of anorexia nervosa and emotionally unstable personality disorder. Her conditions resulted in acts of self-harm which included overdoses. Initially Alice’s overdoses involved over the counter medication such as paracetamol but during 2019 she began to buy prescription medication on line. Alice’s internet search history included visiting sites which promoted suicide. Poisons Act 1972, as a certain means of dying by suicide. 2020 Alice bought quantity of the substance died at her home in Wiltshire on 28th February 2020. On 11th February from the company and having consumed a a reportable poison under the 5 CORONER’S CONCERNS During the course of the inquest the evidence 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 MATTER OF CONCERN is as follows. – is a reportable substance under the Poisons Act 1972. A supplier of the substance has a statutory duty to report any suspicious transaction. The statute goes on to give guidance so as to determine what might be a suspicious transaction. Section 3C (4) reads “In deciding whether there are reasonable grounds for suspecting such a thing, regard must be had to all the circumstances of the case, including in particular where the prospective customer— 1 (a)appears unclear about the intended use of the substance, (b)appears unfamiliar with the intended use of the substance or cannot explain it plausibly, (c)intends to buy substances in quantities, combinations or concentrations uncommon for private use, (d)is unwilling to provide proof of identity or place of residence, or (e)insists on using unusual methods of payment, including large amounts of cash.” Evidence at the inquest suggested that it would not be possible for a mail order business to make such checks. Reference during the inquest was made to eBay’s Hazardous Materials Policy and it was seen that Reportable Poisons in concentrated form were not included in the list of prohibited items. 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 25th June 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 Alice’s family, South Wilts Grammar School, Avon & Wiltshire Mental Health Partnership NHS Trust, Wiltshire Council, Oxford Health NHS Foundation Trust and Red Jackets. I have also sent a copy to the former managing director of 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. 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. 9 Dated this 29th day of April 2026 NICHOLAS RHEINBERG 2
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.
EBAY (UK) LTD Nicholas Rheinberg Assistant Coroner 26 Endless Street Salisbury Wiltshire SP1 1DP 16 June 2026 Subject: Response to Regulation 28 Report Dear Mr Rheinberg, Thank you for your letter dated 29 April 2026 following the inquest into the tragic death of Alice Sarah Dearden. We offer our deepest condolences to her family. We note the concerns raised in your Regulation 28 Report, specifically regarding eBay's Hazardous Materials Policy not explicitly including Reportable Poisons in the list of prohibited items. We understand the critical importance of these matters and the need for assurance in our protective measures. We would like to share details on our policies and enforcement measures dedicated to preventing the sale of harmful substances on our platform, and information on the action we have taken and our updated policy in light of your letter. Hazardous Materials Policy eBay's Hazardous Materials Policy explicitly prohibits the sale of poisons. It states at the start: "Hazardous materials such as poisons, explosive precursors, corrosive substances, ozone depleting substances, radioactive materials and items that contain or release such substances are generally prohibited on eBay." It then goes on to say: "The following are not allowed: (cid:127) Poisons and carcinogenic substances" This prohibition encompasses all poisons, including those classified as a 'reportable poison'. This includes in its pure form, as well as other dangerous items. Further information is also provided to users via a link to the Home Office site towards the end of the policy. We acknowledge however that the explicit inclusion of 'reportable poison' within our policy's general prohibition on poisons may not have been clear, despite them being prohibited on the site. In order to drive clarity, we have updated our policy to now explicitly refer to reportable poisons as being prohibited. This update has already been made and is visible in the policy linked to above. For ease of reference, it now states: EBAY (UK) LIMITED, REGISTERED IN ENGLAND AND WALES WITH NUMBER 03726028 EBAY (UK) LTD 1 MORE LONDON PLACE, LONDON, SE1 2AF T +44(0)20 8156 5666 "The following are not allowed: (cid:127) Poisons (including any 'reportable poisons') and carcinogenic substances" Enforcement in its pure form is not a new addition. It has been prohibited on eBay, in the The prohibition of UK and in other countries where eBay operates, for several years. eBay has proactive measures, including advanced block filter algorithms and Al-supported monitoring, dedicated to identifying and removing unsafe listings. In 2025 for example, 98.2% of prohibited listings globally (which encompasses a wide variety of prohibited items) were blocked at the point of listing creation and did not appear on the eBay marketplace. We also work with regulators, including Trading Standards, the Home Office and the Office of Product Safety and Standards, on our measures and update our filters if there's anything to suggest that they are being circumvented or not working as intended. As an example of our work in this space, we were contacted recently by a UK regulator regarding the risks associated with , which are derived from the highly toxic species of . eBay was already aware of these items and they had been prohibited on eBay sites for years prior to the UK regulator informing us of them.1 Violence and Violent Criminals Policy In addition to our Hazardous Materials Policy, our Violence and Violent Criminals Policy prohibits any products or content that encourages or promotes suicide or self-harm. Any such products, irrespective of being a reportable poison or not, would be removed from the site. Commitment to Safety and Enforcement We want to reiterate our absolute commitment to preventing the sale of dangerous substances on our platform. We have continued to strengthen our enforcement through block filter algorithms, and Al-supported monitoring by our team of in-house specialists. eBay also takes enforcement action against any seller trying to list prohibited items, and we will continue to work tirelessly to prevent the sale of such items. We hope this response clarifies our position, policies, and the robust measures we have implemented to address the concerns raised. We are dedicated to working with regulatory bodies to maintain a safe marketplace and trust that our update of our policy to drive clarity on what is and isn't permitted on the site following your letter, alongside our enforcement measures, showcases this. Finally, and most critically, we want to reiterate our condolences to the family of Alice Sarah Dearden. Director eBay (UK) Limited 1 We would view this as confidential in the event you choose to share the response with other parties as: a) we believe it would be best not to provide details of such substances as individuals who are seeking to self-harm may in turn search specifically for such products; and b) we do not have permission from the regulator in question to provide this information. EBAY (UK) LIMITED, REGISTERED IN ENGLAND AND WALES WITH NUMBER 03726028
See every Prevention of Future Deaths report matching Nicholas Rheinberg, 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.