Stella LeClaire
PFD Report
All Responded
Ref: 2025-0619
All 1 response received
· Deadline: 12 Feb 2026
Coroner's Concerns (AI summary)
The rising number of deaths from a substance sold for suicide raises concerns, emphasizing the need for routine toxicological analysis to improve evidence for potential prosecutions against suppliers.
View full coroner's concerns
1. During the course of the inquest I received information from the Toxicology service, that serves my court, that the number of requests by coroners, in 6 coroner areas, for analysis of blood samples for the presence of , had increased since 2021.
2. I am also aware that in the last 5 years prevention of future death reports have been submitted from a number of other coroner areas. In broad terms the reasons for those reports are concerns that the substance is sold advocating its use in suicides method.
3. Although there was circumstantial evidence that Stella died from toxicity, I was at pains to obtain a specialist toxicological analysis of a blood sample. The reason for this was to ensure that if the supplier of the substance can be identified in future the chances of successful prosecution would be improved by direct evidence of the cause of death. I raise this in case the Chief Coroner may wish to consider issuing guidance on whether blood toxicological analysis should be obtained routinely in coroners’ investigations concerning poisoning.
2. I am also aware that in the last 5 years prevention of future death reports have been submitted from a number of other coroner areas. In broad terms the reasons for those reports are concerns that the substance is sold advocating its use in suicides method.
3. Although there was circumstantial evidence that Stella died from toxicity, I was at pains to obtain a specialist toxicological analysis of a blood sample. The reason for this was to ensure that if the supplier of the substance can be identified in future the chances of successful prosecution would be improved by direct evidence of the cause of death. I raise this in case the Chief Coroner may wish to consider issuing guidance on whether blood toxicological analysis should be obtained routinely in coroners’ investigations concerning poisoning.
Responses
Noted
(AI summary)
(AI summary)
View full response
Dear Mr Williams,
Thank you for the Regulation 28 report of 9 December 2025 sent to the Secretary of State for Health and Social Care about the death of Stella Elizabeth LeClaire. I am replying as the Minister with responsibility for Women’s Health and Mental Health.
Firstly, I would like to say how saddened I was to read of the circumstances of Stella’s death and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. Thank you for the additional time provided to the department to provide a response to the concerns raised in the report.
The report raises concerns over a number of issues which you believe may pose a risk of further deaths if not addressed. You note that coroners in several areas have increasingly needed to request specialist laboratory analysis to detect the presence of a particular substance in blood samples, reflecting wider patterns seen since 2021. You also highlight the continued online availability of this substance, including instances where websites advocate its use in suicides. In addition, you emphasise the importance of obtaining specialist toxicological testing in this case to help establish the cause of death and suggest that the Chief Coroner may wish to consider whether more consistent guidance on when such testing should be sought would be beneficial for future investigations.
The Department recognises the importance of understanding emerging methods of suicide and the need to coordinate activity across government to reduce the risks they pose. As part of this work, we monitor concerning trends through the Concerning Methods Working Group, which brings together representatives from across government, policing, academia, the NHS and the voluntary sector. This group supports the rapid sharing of intelligence, including patterns that may be reflected in requests made by coroners for toxicology analysis, with the aim of enabling swift cross‑government action where needed. The Working Group also includes representation from the coroner community, ensuring that learning from Prevention of Future Deaths reports forms an important part of how emerging risks are identified and addressed.
A significant part of the group’s work has focused on limiting public access to the substance involved in this and other cases, and more than 30 targeted actions have been taken to reduce opportunities to obtain it for non‑legitimate purposes. These include operational work with online suppliers, platforms and manufacturers to raise safeguarding concerns, restrict availability, and prevent its sale in particularly concerning ways, including on online forums. Government departments have also worked with online platforms to reduce opportunities for the substance to be purchased by individuals. We are also exploring opportunities to work with Border Force, using existing legal provisions, to improve detection of packages that may be linked to vulnerable individuals. The group monitors the effectiveness of these measures and continues to consider future opportunities for action as new intelligence emerges.
You also raise the question of whether more consistent guidance on obtaining specialist toxicology might support coroner investigations in these types of cases. As you will know, decisions on issuing guidance rest with the Chief Coroner. Your report has been shared with them, and the Department will continue to work closely with the Chief Coroner’s Office, which is represented on the Concerning Methods Working Group, to ensure that learning from PFD reports, intelligence from coroners, and suggestions for further action are fully considered within existing responsibilities.
More broadly, as part of our mission to build an NHS fit for the future, the Government has committed to tackling suicide as one of this country’s biggest killers. Ultimately, our aim is to provide help and support as early as possible so that people do not feel the need to turn to these types of substances to take their own life.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Thank you for the Regulation 28 report of 9 December 2025 sent to the Secretary of State for Health and Social Care about the death of Stella Elizabeth LeClaire. I am replying as the Minister with responsibility for Women’s Health and Mental Health.
Firstly, I would like to say how saddened I was to read of the circumstances of Stella’s death and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. Thank you for the additional time provided to the department to provide a response to the concerns raised in the report.
The report raises concerns over a number of issues which you believe may pose a risk of further deaths if not addressed. You note that coroners in several areas have increasingly needed to request specialist laboratory analysis to detect the presence of a particular substance in blood samples, reflecting wider patterns seen since 2021. You also highlight the continued online availability of this substance, including instances where websites advocate its use in suicides. In addition, you emphasise the importance of obtaining specialist toxicological testing in this case to help establish the cause of death and suggest that the Chief Coroner may wish to consider whether more consistent guidance on when such testing should be sought would be beneficial for future investigations.
The Department recognises the importance of understanding emerging methods of suicide and the need to coordinate activity across government to reduce the risks they pose. As part of this work, we monitor concerning trends through the Concerning Methods Working Group, which brings together representatives from across government, policing, academia, the NHS and the voluntary sector. This group supports the rapid sharing of intelligence, including patterns that may be reflected in requests made by coroners for toxicology analysis, with the aim of enabling swift cross‑government action where needed. The Working Group also includes representation from the coroner community, ensuring that learning from Prevention of Future Deaths reports forms an important part of how emerging risks are identified and addressed.
A significant part of the group’s work has focused on limiting public access to the substance involved in this and other cases, and more than 30 targeted actions have been taken to reduce opportunities to obtain it for non‑legitimate purposes. These include operational work with online suppliers, platforms and manufacturers to raise safeguarding concerns, restrict availability, and prevent its sale in particularly concerning ways, including on online forums. Government departments have also worked with online platforms to reduce opportunities for the substance to be purchased by individuals. We are also exploring opportunities to work with Border Force, using existing legal provisions, to improve detection of packages that may be linked to vulnerable individuals. The group monitors the effectiveness of these measures and continues to consider future opportunities for action as new intelligence emerges.
You also raise the question of whether more consistent guidance on obtaining specialist toxicology might support coroner investigations in these types of cases. As you will know, decisions on issuing guidance rest with the Chief Coroner. Your report has been shared with them, and the Department will continue to work closely with the Chief Coroner’s Office, which is represented on the Concerning Methods Working Group, to ensure that learning from PFD reports, intelligence from coroners, and suggestions for further action are fully considered within existing responsibilities.
More broadly, as part of our mission to build an NHS fit for the future, the Government has committed to tackling suicide as one of this country’s biggest killers. Ultimately, our aim is to provide help and support as early as possible so that people do not feel the need to turn to these types of substances to take their own life.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Sent To
- Secretary of State for Health and Social Care [REDACTED]
- Secretary of State for the Home Department [REDACTED]
Response Status
Linked responses
1 of 2
56-Day Deadline
12 Feb 2026
All responses received
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 1/8/23 a coroner’s investigation was commenced into the death of Stella Elizabeth LeClaire, formerly known as Mia Levy. The inquest was concluded on the 4/12/2025.
Circumstances of the Death
1. On the 28/7/23 at 16:46 pm Stella checked into a hotel in Tooley Street, Southwark. Hotel electronic key records show that she did not leave the room after she checked in. On the 30/7/23 she was discovered unresponsive by hotel staff at 13:45 pm and was subsequently pronounced dead by the ambulance service at 14:56 pm.
2. A police investigation revealed she had sent a farewell email message, to her partner in the United States, timed to be sent at 10:31 am on the 30/7/23, expressing that she could not continue living with constant migraines and nausea and that her health was getting worse. It had not been possible to access Stella’s phone and laptop for logistical reasons, but her partner disclosed the email to the police shortly after receiving it.
3. in a container recovered from the room, was analysed and found to contain . It is not known who supplied the to her and the circumstances in which she obtained it.
4. A post-mortem identified the cause of death as 1(a) toxicity. This finding was inferred from circumstantial evidence by the post-mortem pathologist.
5. A routine toxicology screening report also detected , an antiemetic, which has been taken alongside in other reported cases.
6. A further toxicology report from a specialist toxicology service, analysed a femoral blood sample, taken at autopsy. This report confirmed the level of was extremely high and that it was ‘highly likely’ that this caused the death.
7. Stella had taken the with the intention of ending her own life and I recorded a short form conclusion of “Suicide” in the Record of Inquest.
2. A police investigation revealed she had sent a farewell email message, to her partner in the United States, timed to be sent at 10:31 am on the 30/7/23, expressing that she could not continue living with constant migraines and nausea and that her health was getting worse. It had not been possible to access Stella’s phone and laptop for logistical reasons, but her partner disclosed the email to the police shortly after receiving it.
3. in a container recovered from the room, was analysed and found to contain . It is not known who supplied the to her and the circumstances in which she obtained it.
4. A post-mortem identified the cause of death as 1(a) toxicity. This finding was inferred from circumstantial evidence by the post-mortem pathologist.
5. A routine toxicology screening report also detected , an antiemetic, which has been taken alongside in other reported cases.
6. A further toxicology report from a specialist toxicology service, analysed a femoral blood sample, taken at autopsy. This report confirmed the level of was extremely high and that it was ‘highly likely’ that this caused the death.
7. Stella had taken the with the intention of ending her own life and I recorded a short form conclusion of “Suicide” in the Record of Inquest.
Copies Sent To
: The Metropolitan Police Service and Nadia Persaud Area Coroner for East London
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.