Samuel Dickenson

PFD Report All Responded Ref: 2025-0252
Date of Report 23 May 2025
Coroner Timothy Brennand
Coroner Area Manchester West
Response Deadline est. 18 July 2025
All 1 response received · Deadline: 18 Jul 2025
Sent To
Response Status
Responses 1 of 1
56-Day Deadline 18 Jul 2025
All responses received
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Chief Coroner's Non-Response List

The Chief Coroner has confirmed that the following organisation did not respond within the required period:

Coroner's Concerns
_ is a reportable poison as well as a reportable explosives precursor within the terms, meaning and effect of Part 4 of Schedule 1A of the Poisons Act 1972 with the consequence that:
a. The Poisons Act 1972 sets out the legal obligations in relation to the sale, purchase, and use of these chemicals for suppliers, professional users and members of the public:
b. The published Guidance (commenced in 2014 and updated in August does not give specific guidance or suggested training to sellers, particularly Sodium Nitrate/Nitrite acquired by members of the public, particularly over `online marketplaces' in circumstances of the purchase on a one off' basis for the means of self-harming: C. Whilst there is a legal duty on persons selling this substance to report "suspicious" transactions within 24 hours to the Home Office, the purchase of small quantities is being presumed to be connected to the many legitimate uses of the substance (such as food preservation, fertilizer etc) rather than in fact, being evaluated as a member of the public seeking purchase of modest quantities used as their chosen means by which to end life-
d. The current Home Office guidance and supporting video, leaflet and posters do not reference as a specific example of concern and focuses on the phenomenon of 'malicious' misuse and not deliberate misuse in the sense of suicide/self-harm_
2. The police investigation into one UK based source of supply revealed in 247 cases separate supplies of 500 grams of less of to customers in the UK and Europe, police established that 85 of these individuals who were traceable had either died as the consequence of self-ingestion of the substance, or had purchased it with a view to having the means to use this method to end their life in circumstances where: a, the vendors of the were not aware of this potential misuse of the substance:
b. the small quantities being purchased had been incorrectly evaluated to be an increase in individuals pursuing recreational home-curing/food preservations as a hobby, being a artefact of "lockdown' living following the COVID national pandemic emergency. C. Vendors were unaware that their website/details were being distributed as part of internet information platforms designed to aid, abet, assist or promote suicide methods:
d. From the specific example of 247 supplies in a 12 month period, police established that 45 purchasers were confirmed as deceased (these deaths were in relation to supplies to UK customers and purchasers from abroad) and only 15 purchases were confirmed to have taken place for ligitimate purposes (meat curing etc ).
3. The police investigation revealed the ability of members of the public to access a number of websites, primarily created in the USA, Canada and Mexico that promoted information as to how to access:
a. Poisons that could bring about death
b. How, in what way and with with ther necessary preparations (in particular -antiemetic medications) the poisons should be administered_ Sourcing such poisons/chemicals/medications in the UK and abroad_ Regulation 28_ After Inquest Document Template Updated 30/07/2021 2024)
Responses
Home Office
4 Mar 2026
The Home Office refers to a previous response outlining existing measures. It highlights the cross-Government Suicide Prevention Strategy and the Concerning Methods Working Group. The Online Safety Act has been amended to make encouraging self-harm a priority offence, with officials continuing to consider further legislative and non-legislative measures. AI summary
View full response
Dear Mr Brennand,

Thank you for your Regulation 28 reports sent to the Home Secretary following the tragic deaths of William James Armstrong, Shaun Michael Bass, Mathew Anthony Price, Kelly Michelle Walsh, Chantelle Williams, Samuel David Dickenson and Matthew Joseph O'Reilly.

I am responding on behalf of the Home Secretary, in my capacity as the Minister of State responsible for the Poisons Act. I would firstly like to apologise for the delay in responding. Due to an administrative error, these reports were only recently received by the department. I would also like to extend my deepest condolences to their families and thank you for sharing the concerns raised in your reports, which I have carefully noted. I am grateful to you for bringing these matters to my attention.

I acknowledge the issues you have raised, specifically around guidance and training for suppliers and concerns regarding online suicide forums. These important issues were addressed in my response to the PFD report following the inquest into the tragic death of Andrew Brown, sent to you on 22 July 2025. To assist I have enclosed a summary of that letter setting out Government's response on these matters (Annex A). Further to this summary, I wish to set out the action being progressed across Government and clarify the Home Office’s role and the steps taken to date.

The Department for Health and Social Care (DHSC) published the cross- Government Suicide Prevention Strategy for England (2023-2028) in September
2023. The Home office supports DHSC in delivering this strategy, including by staking targeted action to address emerging methods of suicide.

DHSC convene a Concerning Methods Working Group (CMWG), which brings together a wide range of expertise from other government departments – including the Home Office – alongside academics, voluntary sector organisations, law enforcement, the NHS and coroner representatives. The Group’s purpose is to identify, limit awareness of and reduce access to emerging methods of suicide.

This reflects the government’s commitment to a responsive and adaptive approach, ensuring responses are informed by the latest intelligence and trends. Through this forum, stakeholders have been examining the current understanding of the use sodium nitrite and sodium nitrate in suicides.

Sodium nitrite is subject to several legislative regimes, including REACH and food safety legislation. It is also a reportable poison under Part 4 of Schedule 1A of the Poisons Act 1972. This means it may be sold to the public, but retailers must report suspicious transactions to the Home Office where they have grounds to suspect illicit use.

The Poisons Act supports the aims of the Government’s Counter Terrorism Strategy, CONTEST, by enabling controls on chemicals and poisons that may be used to cause harm, while ensuring legitimate access for lawful uses. The legislation applies only to Great Britain (i.e. England, Scotland, and Wales), and there is no obligation for retailers based outside this jurisdiction to report suspicious transactions.

The Homeland Security Group oversee the Poisons Act for counter-terrorism purposes and works closely with other government departments in recognition that the legislation may also support wider public safety issues, including suicide prevention. My officials are working collaboratively with DHSC to assess whether, and how, the Poisons Act could play a meaningful role in reducing harm in this context. More generally, the Home Office keeps legislation under regular review to ensure it remains proportionate, evidence-based, and aligned with national security and public safety objectives.

While sodium nitrite remains widely used for legitimate purposes (e.g., food curing, industrial applications), retailers in Great Britain are legally obliged to report suspicious transactions under the Poisons Act 1972. Border Force officers have been issued guidance on identifying and intercepting consignments suspected for self-harm use. The Home Office also engages with online platforms to encourage voluntary removal of listings for high purity sodium nitrite.

To answer your questions about further regulation for sodium nitrite, as noted above, DHSC and Home Office are working with stakeholders to consider whether additional regulation would be effective and proportionate, and if so, which body would be best placed to take forward any such work.

Adding sodium nitrite as a regulated poison under Part 2 of Schedule 1A of the Poisons Act 1972 would make it a criminal offence for a retailer to supply it to a member of the public without a Home Office licence; and a criminal offence for a member of the public to import, acquire, possess or use it without a licence. However, this could impose burdens on businesses and consumers who currently use it lawfully. Evidence also indicates that most harmful purchases originate from overseas suppliers, which fall outside UK legislative control. Making sodium nitrite a regulated poison under the Poisons Act 1972 would also criminalise the buyer. These points are actively being considered in the conversations between departments.

Finally, I understand the troubling concerns you have raised about the pro-suicide forums. DSIT, as the department responsible for the Online Safety Act, is committed to working with Ofcom and bereaved families. This partnership aims to ensure the Act protects all users from illegal suicide and self‑harm content and shields children from harmful material that does not meet the criminal threshold.

Whilst the introduction of the Online Safety Act marked an important first step toward securing safer online environments, the Government recognises the need to keep the legislation under review and is committed to identifying where further strengthening may be required. Since being appointed, DSIT’s Secretary of State, Liz Kendall, has ensured there are stronger protections for vulnerable users by amending the Act to make encouraging self-harm a priority offence. This triggers the strongest possible legal protections, requiring in-scope services to proactively prevent all users from being exposed to this content, as well as minimising the length of time for which such content is present.

I hope this explanation is helpful in setting out the scope of the Home Office’s responsibilities and the collaborative work underway across government. Preventing access to harmful substances is a priority I take extremely seriously, and the Home Office remains absolutely committed to supporting DHSC, coroners and law enforcement partners in reducing the risks associated with sodium nitrite.

Thank you again for sharing these reports. I have asked my officials to continue considering further measures, legislative and nonlegislative, in light of emerging evidence and trends.
Report Sections
Investigation and Inquest
On 04 September 2020 [ commenced an investigation into the death of Samuel David Dickenson aged 33. The investigation concluded at the end of the inquest on 09 August 2022 The medical cause of death was determined to be 1a (toxicity I returned a short form conclusion that Samuel David Dickenson died as the reuslt of suicide_ Reporting restrictions were imposed in this case because of an ongoing criminal investigation in the United Kingdom, Europe and the United States of America, the case being one of a cluster of eight similar cases upon the Greater Manchester West jurisdiction. Reporting restrictions were lifted on the 19th of April 2024. This report is being published following updates from Greater Manchester Police and suicide prevention organisations received on the 14th of March 2025.
Circumstances of the Death
The deceased had a history of known episodic low mood, anxiety and depression that had been treated conservatively in the community. At 2.1Sam on the 11th of March 2020, North West Ambulance Service received a telephone call from the deceased, disclosing that he had recently consumed a quantity of that he had acquired over the internet: Emergency services promptly attended at his residence at Leigh and discovered the deceased , collapsed and unresponsive in his bedroom: Active resuscitation was commenced, and the deceased was transferred to Royal Albert Edward Infirmary, Wigan. He failed to respond to active and sustained further attempted resuscitation and was confirmed dead at 3.52am that morning: From within the deceased's residence, police recovered padded postal envelope addressed to the deceased next to an opened sealable sachet labelled Pure 99.9% SOg" that the deceased had acquired on the 21st of February 2020 from an internet-based company licensed to sell controlled poisons, including On the deceased'$ computer, police recovered a document titled 'Suicide Note txt" containing unequivocal expressions of his intent bag

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.