Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Samuel Duckworth · 20 Oct 2014 · Andrew Harris, London (Inner South)
“He was only prescribed a small amount of Diazepam, which | infer is because of the risks of abuse. Yet he had no difficulty in purchasing these prescription only drugs on the internet, 20 empty packets being found at the scene”
judiciary.uk/prevention-of-future-death-reports/samuel-duckworth
What was promised
Stated action 1 · response to Samuel Duckworth (20 Oct 2014) · stated timescale: none stated
“The Government and law enforcement agencies take the issue of unlawful advertising and sales of drugs on the internet very seriously, and we continue to work with internet providers to ensure that they comply with the law. This can include closure of UK-based websites where they are found to be committing offences under the Misuse of Drugs Act 1971.”
Stated action 2 · response to Linda Gillchrest (4 Jan 2021) · stated timescale: none stated
“I am advised that suicide prevention policy leads in the health system, at the Department of Health and Social Care, Public Health England (PHE), and NHS England and NHS Improvement (NHSEI), are alert to the risk posed by websites promoting suicide methods, and their direction on the use of certain chemicals in completing suicide, including the substance taken by Mrs [name redacted]. These organisations, along with key stakeholders and academics, are looking at what data is available on suicides by this”
judiciary.uk/…/2021-0002-Response-from-Dept-of-Health-and-Socia…
Stated action 3 · response to Neha Raju (14 Oct 2022) · stated timescale: none stated
“The MHRA have advised that they are responsible for regulating the substance used in this case, when it is used as a licensed medicine, in the form of a solution for injection. It is a prescription only medicine and has an indication for cyanide poisoning. This substance in other forms is used in other sectors, such as food manufacturing. However, when the purchase of this substance over the internet is not a licensed medicine, or counterfeit medicine, it is not within the remit of the MHRA.”
judiciary.uk/…/2022-0319-Response-from-Department-of-Health-and…
What recurred
- 30 Oct 2017 · Jane Powell · Lisa Hashmi · Identical hazard · confidence 0.92 (high)
- 4 Jan 2021 · Linda Gillchrest · Richard Travers
- 14 Oct 2022 · Neha Raju · Anna Loxton · Identical hazard · confidence 0.90 (high)
- 30 Jul 2024 · Bethany Langton · Laurinda Bower · Identical hazard · confidence 0.92 (high)
The clearest link, quoted from both reports:
Earlier · Neha Raju · 14 Oct 2022
“is freely available to be purchased from the internet in lethal quantities for delivery within the UK”
Later · Bethany Langton · 30 Jul 2024
“The substance is readily available to purchase online without the need for any explanation of the purchaser's intended use for the substance”
What happened next
No evidence found either way · stated action 2
“National Strategy for Suicide Prevention. Washington, DC: HHS, April 2024.”
2024 National Strategy for Suicide Prevention · hhs.gov/…/national-strategy-suicide-prevention.pdf
“Public Health England exists to protect and improve the nation's health and wellbeing, and reduce health inequalities.”
Preventing suicides in public places – A practice resource · assets.publishing.service.gov.uk/…/Preventing_suicides_in_publi…
“An evidence-based systems approach to suicide prevention: guidance on planning, commissioning, and monitoring.”
An evidence-based systems approach to suicide prevention · health.gov.au/…/an-evidence-based-systems-approach-to-suicide-p…
No evidence found does not mean the action did not happen.