Andrew Kenward
PFD Report
All Responded
Ref: 2025-0346
All 2 responses received
· Deadline: 3 Sep 2025
Response Status
Responses
2 of 2
56-Day Deadline
3 Sep 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
Coroner’s Concerns
A lethal dose of can be as small as 1g. Mr Kenward was able to procure a total of 1kg of at 99.999% purity.
Coroners including myself have previously raised in Prevention of Future Death reports that there is no central monitoring system which is able to record incidents of sodium nitrite poisoning, although the use of sodium nitrite for self-harm is increasing.
and are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. Whilst the source of this particular is not currently known, there are no restrictions on the import of or from abroad.
Whilst these substances have legitimate uses, including meat preservation, there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose.
can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions;
- can be purchased from abroad and imported to Great Britain with no restrictions;
- is sold at levels of purity (99%) and in quantities which represent significant risk to life (up to 1000 fatal doses for 1kg sale), whether by self-harm or terrorist use;
- The quantities and purity in which are sold do not appear to be those required for their legitimate use, for example in meat preservation;
- It does not appear there is any consideration of regulating/monitoring the use of outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this.
Coroners including myself have previously raised in Prevention of Future Death reports that there is no central monitoring system which is able to record incidents of sodium nitrite poisoning, although the use of sodium nitrite for self-harm is increasing.
and are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. Whilst the source of this particular is not currently known, there are no restrictions on the import of or from abroad.
Whilst these substances have legitimate uses, including meat preservation, there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose.
can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions;
- can be purchased from abroad and imported to Great Britain with no restrictions;
- is sold at levels of purity (99%) and in quantities which represent significant risk to life (up to 1000 fatal doses for 1kg sale), whether by self-harm or terrorist use;
- The quantities and purity in which are sold do not appear to be those required for their legitimate use, for example in meat preservation;
- It does not appear there is any consideration of regulating/monitoring the use of outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this.
Responses
The Home Office is researching the availability of sodium nitrite and collaborating with DHSC on legislative options. Border Force issued guidance last year on controlling items intended to assist suicide, and the Home Office continues to engage with industry to promote responsible sales practices and enhance retailer awareness of reporting obligations.
AI summary
View full response
Dear Ms Loxton,
ANDREW NATHAN PAUL KENWARD REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
Thank you for the Regulation 28 report, dated 9 July 2025, sent to the Home Secretary following the inquest into the death of Andrew Kenward, who tragically died on 24th October 2022. I am responding on behalf of the Home Secretary, as the Security Minister.
Firstly, I would like to extend my sincere condolences to Mr Kenward’s family and loved ones. We are very grateful for your careful consideration of the risks posed by the substance mentioned in your report, and for raising these important matters of public safety.
You have raised a number of concerns, many of which echo those previously highlighted in your report following the inquest into the death of Hannah Aitken. I would like to assure you that the Government continues to take these issues very seriously and is actively working across departments to address them.
The substance in question is currently classified as a reportable substance under the Poisons Act 1972. While this requires GB-based sellers to report suspicious transactions, we acknowledge that this obligation does not apply to sellers based overseas. My officials are currently carrying out research into the availability of the substance in question, both domestically and internationally.
The Home Office supports the Department for Health and Social Care (DHSC) in delivering the Suicide Prevention Strategy for England (2023–2028), which
2
includes targeted action on emerging methods of suicide. In recent months, my officials have been working with the Department of Health and Social Care (DHSC) and other departments to assess the feasibility of additional regulatory and non-regulatory levers for the substance in question. A cross- government workshop took place in June to explore these options. Further meetings will shortly be held between senior officials to agree recommendations for a coordinated government response.
In the meantime, the Home Office continues to engage with industry to promote responsible sales practices. My officials have engaged with selected online platforms and retailers individually to encourage them to voluntarily remove the sale of these substances to members of the public in their pure form, and be vigilant for the possibility of purchase for self-harm or suicide. For all substances within scope of the Poisons Act, the Homeland Security Group works to improve retailer awareness of their legal obligation to report suspicious activity and to inform retailer sales practices. For example, we encourage suppliers to use declaration of use forms for sales of potentially harmful substances. This work will continue to ensure suppliers are meeting their obligations under the Poisons Act.
Furthermore, if during the processing of suspicious activity reports, a safeguarding concern is identified by Counter Terrorism Policing, consideration will be given to disseminating this intelligence to police forces to consider a welfare check.
Moreover, to target potentially harmful acquisitions of this substance from overseas merchants, last year Border Force issued guidance to its officers about the control actions they must take, within existing legal provisions, if they receive any form of information suggesting that goods at the border contain items intended to assist with suicide. This relies on Border Force working closely with police forces and other relevant agencies to safeguard vulnerable individuals to the full extent possible. This work is complex, and Border Force will continue to monitor its policies, exploring opportunities to improve its ability to act where possible and to ensure that frontline Border Force staff who may encounter these items know what action to take and are supported on a case-by-case basis when required.
Thank you again for your report and for your continued efforts to prevent future deaths.
ANDREW NATHAN PAUL KENWARD REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
Thank you for the Regulation 28 report, dated 9 July 2025, sent to the Home Secretary following the inquest into the death of Andrew Kenward, who tragically died on 24th October 2022. I am responding on behalf of the Home Secretary, as the Security Minister.
Firstly, I would like to extend my sincere condolences to Mr Kenward’s family and loved ones. We are very grateful for your careful consideration of the risks posed by the substance mentioned in your report, and for raising these important matters of public safety.
You have raised a number of concerns, many of which echo those previously highlighted in your report following the inquest into the death of Hannah Aitken. I would like to assure you that the Government continues to take these issues very seriously and is actively working across departments to address them.
The substance in question is currently classified as a reportable substance under the Poisons Act 1972. While this requires GB-based sellers to report suspicious transactions, we acknowledge that this obligation does not apply to sellers based overseas. My officials are currently carrying out research into the availability of the substance in question, both domestically and internationally.
The Home Office supports the Department for Health and Social Care (DHSC) in delivering the Suicide Prevention Strategy for England (2023–2028), which
2
includes targeted action on emerging methods of suicide. In recent months, my officials have been working with the Department of Health and Social Care (DHSC) and other departments to assess the feasibility of additional regulatory and non-regulatory levers for the substance in question. A cross- government workshop took place in June to explore these options. Further meetings will shortly be held between senior officials to agree recommendations for a coordinated government response.
In the meantime, the Home Office continues to engage with industry to promote responsible sales practices. My officials have engaged with selected online platforms and retailers individually to encourage them to voluntarily remove the sale of these substances to members of the public in their pure form, and be vigilant for the possibility of purchase for self-harm or suicide. For all substances within scope of the Poisons Act, the Homeland Security Group works to improve retailer awareness of their legal obligation to report suspicious activity and to inform retailer sales practices. For example, we encourage suppliers to use declaration of use forms for sales of potentially harmful substances. This work will continue to ensure suppliers are meeting their obligations under the Poisons Act.
Furthermore, if during the processing of suspicious activity reports, a safeguarding concern is identified by Counter Terrorism Policing, consideration will be given to disseminating this intelligence to police forces to consider a welfare check.
Moreover, to target potentially harmful acquisitions of this substance from overseas merchants, last year Border Force issued guidance to its officers about the control actions they must take, within existing legal provisions, if they receive any form of information suggesting that goods at the border contain items intended to assist with suicide. This relies on Border Force working closely with police forces and other relevant agencies to safeguard vulnerable individuals to the full extent possible. This work is complex, and Border Force will continue to monitor its policies, exploring opportunities to improve its ability to act where possible and to ensure that frontline Border Force staff who may encounter these items know what action to take and are supported on a case-by-case basis when required.
Thank you again for your report and for your continued efforts to prevent future deaths.
The Department of Health and Social Care acknowledges the concerns but states that responsibility for these issues, particularly regarding the procurement of sodium nitrite and related legislation, sits with the Home Office.
AI summary
View full response
Dear Ms Loxton,
Thank you for the Regulation 28 report of 9th July 2025 sent to the Secretary of State / the Department of Health and Social Care about the death of Andrew Nathan Paul Kenward. I am replying as the Minister with responsibility for Mental Health.
Firstly, I would like to say how saddened I was to read of the circumstances of Mr Kenward death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.
The report raises concerns over the fact that Mr Kenward was able to buy large amounts of sodium nitrite. Officials within the Department of Health and Social Care have considered these concerns and concluded that the responsibility for these concerns sits within another organisation. I understand that this report was also made to the Home Office, and I hope that their response will be helpful.
Thank you for bringing these concerns to my attention.
Thank you for the Regulation 28 report of 9th July 2025 sent to the Secretary of State / the Department of Health and Social Care about the death of Andrew Nathan Paul Kenward. I am replying as the Minister with responsibility for Mental Health.
Firstly, I would like to say how saddened I was to read of the circumstances of Mr Kenward death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.
The report raises concerns over the fact that Mr Kenward was able to buy large amounts of sodium nitrite. Officials within the Department of Health and Social Care have considered these concerns and concluded that the responsibility for these concerns sits within another organisation. I understand that this report was also made to the Home Office, and I hope that their response will be helpful.
Thank you for bringing these concerns to my attention.
Report Sections
Investigation and Inquest
Andrew Nathan Paul Kenward died on 24th October 2022, aged 30. His inquest was opened on 2nd May 2023. A summary inquest took place on 17th June 2025. I recorded a conclusion of Suicide. I found the medical cause of death to be: 1a. Toxicity
Circumstances of the Death
Early on the morning of 24th October 2022, Andrew Kenward was found deceased in his car parked on a road in Sunbury on Thames, Surrey, from an overdose of a poisonous substance, namely . Mr Kenward had previously expressed an intention to end his life to a friend and an undated note was found in his bedroom drawer expressing his regret and love for his Family, but that he felt unable to continue living. Two packets of were also found in Mr Kenward’s bedroom, both stated to contain 50g . One of these was sealed and weighed 51.45g. The second was resealable and weighed
Copies Sent To
1. See names in paragraph 1 above
Signed
ANNA LOXTON
DATED this 9th day of July 2025
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.