Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0232, 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 | 2026-0232 |
| Deceased | Alice Dearden |
| Coroner | Nicholas Rheinberg |
| Coroner area | Wiltshire and Swindon |
| Organisation named | Oxford Health NHS Foundation Trust · Avon and Wiltshire Mental Health Partnership NHS Trust |
| Source | judiciary.uk record |
| Responses published | none published |
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: 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. from your company and having consumed a quantity of the substance died at her On 11th February 2020 Alice bought 5 home in Wiltshire on 28th February 2020. 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. – Evidence received at the above inquest included reference to your former company’s website which was seen to still exist. The website includes the detail shown in italics below: PLEASE NOTE: We do NOT sell the concentrated food preservative used in meat curing under any circumstances. We immediately (same day) stopped selling this back in April 2020 when we discovered it's misuse and the name being used - 1 with neither our knowledge nor permission - on a number of dreadful suicide forums We subsequently then worked with and assisted the Home Office Protect team in helping identify many of the other sellers still on eBay, Etsy and Amazon etc. in requesting that they remove their similar listings because of this misuse. 2025 Update: Thankfully, It is now much more difficult for a member of the public to source this substance. However sadly, and despite the work of the NYT and the BBC in exposing it, the websites are still operating and thriving, currently using a .net domain. It has stated that it will not be complying with the new 2025 UK Online Safety law. If you are suffering with your mental health and considering suicide, please do contact the Samaritans 24/7 or call 116 123 if in UK. Worldwide list of suicide help charities is HERE (Wikipedia) There is mention in the above posting, albeit obliquely, to a method of self-destruction, reference to suicide websites and a link to a website encouraging suicide. Concern was expressed at the inquest that were the words in italics not removed individuals of a disturbed disposition, inclined towards deliberate self-harm, might be assisted in their endeavours harm themselves. 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 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 3
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