William Armstrong
PFD Report
No Identified Response
Ref: 2025-0257
Alcohol, drug and medication related deaths
Emergency services related deaths (2019 onwards)
Mental Health related deaths
251 days past deadline · No identified published response
Sent To
Response Status
Responses
0 of 1
56-Day Deadline
18 Jul 2025
251 days past deadline — no identified published response
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 ad members of the public: The published Guidance (commenced in 2014 and updated in August 2024) does not give specific guidance or suggested training to sellers, particularly acquired by members of the public, particularly over 'online marketplaces' in circumstances of the purchase on 'one off' basis for the means of self-harming: 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. The current Home Office guidance and supporting video, leaflet ad 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 an artefact of 'lockdown 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.
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 other necessary preparations (in particular -antiemetic medications) the poisons should be administered_ C. Sourcing such poisons/chemicals/medications in the UK and abroad
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 ad members of the public: The published Guidance (commenced in 2014 and updated in August 2024) does not give specific guidance or suggested training to sellers, particularly acquired by members of the public, particularly over 'online marketplaces' in circumstances of the purchase on 'one off' basis for the means of self-harming: 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. The current Home Office guidance and supporting video, leaflet ad 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 an artefact of 'lockdown 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.
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 other necessary preparations (in particular -antiemetic medications) the poisons should be administered_ C. Sourcing such poisons/chemicals/medications in the UK and abroad
Action Should Be Taken
YoUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by May 16, 2025. 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_
Report Sections
Investigation and Inquest
On 30 March 2023 I commenced an investigation into the death of William James Armstrong aged 24_ The investigation concluded at the end of the inquest on 06 June 2023. The medical cause of death was determined to be: 1a_ Toxicity [ returned a narrative conclusion that William James Armstrong died as the consequence of the effects of a significant quantity ofl deliberately self-administered in circumstances where his intentions remain unclear by reason of a combination of recently consumed alcohol and a prodromal insidious onset of an undiagnosed psychotic illness. 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 that had included episodic low mood, with fleeting examples of previous suicidal ideation, but no formal mental health diagnosis had been made. He had been treated conservatively and discharged by Iocal community-based mental health services following the deceased's non-engagement In October 2022, a consultant psychiatrist assessed the deceased to be in a phase of gradual decline with fluctuating symptoms that included hallucinations with distorted thinking and perception suggestive of a prodromal insidious onset of a psychotic illness with decline in social functioning. The views of the psychiatrist were communicated to the deceased's general practitioner, who having discussed matters with the deceased and his family, persevered with a conservative, reactive pathway of primary care and did not refer the deceased to further community mental health intervention as suggested by the psychiatrist; but whether this decision had any bearing upon the outcome remains unclear_ At 10.S8pm on the 22nd of May 2021, North West Ambulance Service received an emergency call from the deceased, informing them that he had consumed an quantity ofF with 'metformin blue' 15 minutes earlier , that he was now not breathing normally and in effect, he was seeking to be rescued_ The call was categorised as a 'Category 2' response using the prevailing Medical Priority Dispatch System. By reason of operational conditions that evening, there was an 89-minute delay in response with an ambulance arriving on scene at 11.27pm. The deceased was found collapsed, unresponsive in room 49 of the hotel_ He failed to respond to resuscitation and was confirmed as dead at 11.37pm. Police investigations established that the deceased had booked into the hotel at about 9pm that night and had earlier acquired theb Jusing the internet from a source in Russia. No note or other evidence of intention was discovered. Toxicological samples from the deceased confirmed the presence of significant levels of alcohol and a fatally toxic amount of albeit the precise quantity or time of ingestion could not be quantified. The consequence of the delayed paramedic response cannot be established due to the rapidity of effect and highly toxic consequence of methemoglobinemia that arises following ingestion of
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.