Coroner issues prevention of future deaths reports over poisonous substances

Hannah Aitken, 22, died on September 14, 2023, at her supported living accommodation in Caterham after taking a poisonous substance.

The family of the young woman who took her own life are also calling for urgent action to “avoid a repeat of such tragedies in future”. Described by her dad as “bright, kind and with a beautiful smile”, Miss Aitken tragically died from a substance she ordered online from abroad. She had a long-standing mental health battle of anxiety and depression, as well as autism spectrum disorder and ADHD.

Anna Loxton, Assistant Coroner for Surrey, has written a Prevention of Future Death Report, published 14 November, to flag the issue of the dangerous availability of poisonous substances and its ongoing risk to the public. The report is addressed to the Secretaries of State for the Home Office and the Department of Health and Social Care calling on them to take action.

The Home Secretary recently provided reassurance in response to another death: Dr Jonathan Shaw, who died in Oldham in April 2024. The response read: “The Home Office is actively exploring legislative and policy options, including working with or alongside officials of other Government Departments as appropriate, for the control of [REDACTED] (and other similar substances).”

During Miss Aitken’s inquest, which concluded on November 7, the court heard anecdotal evidence from three emergency medical consultants and other witnesses that in their direct experience, the use of poisonous substances for self-harm is increasing. However, none of them were aware of a standard central monitoring system which is able to record incidents of such poisoning.

Although there may not be an active monitoring system, the Department of Health and Social Care recently released a report investigating changing trends in suspected suicide for England from May 2023 to July 2024. It found that poisoning was the second most frequent method and accounts for nearly 20% of all suicides.

Ms Loxton raised concerns that poisonous substances, such as those used in Miss Aitken’s case, can be purchased with no restrictions. The emphasis is on the seller to report any suspicious transactions and to clarify what the buyer intends to use it for. She also highlighted that these substances can be bought from abroad and imported with no restrictions. Ms Loxton questioned why large quantities and purities of the poison are being sold, when only a small amount is required for its legitimate use.

During Miss Aitken’s inquest, the court heard that the current Poisons Act 1972 relates to terrorism in controlling access to explosive precursors and poisons. Prevention of suicide/self-harm is not part of the policy of this act under the Home Office and so falls to the remit of Department for Health and Social Care.

“No evidence was provided that there is active consideration of controlling access to these substances to the general public, whether under the remit of the Home Office or any other Government department,” the report found. Ms Loxton stressed it is “not clear” which government department is responsible for monitoring poisonous substances outside the Poisons Act 1972.

A Home Office spokesperson said: “Our thoughts continue to be with the families and friends of Hannah Aitken and those who have sadly lost their life due to this substance. Once received, Ministers will consider the Coroner’s report carefully.”

The Department of Health and Social Care has been contacted for comment.