Chantelle Williams
PFD Report
All Responded
Ref: 2025-0255
All 1 response received
· Deadline: 18 Jul 2025
Coroner's Concerns (AI summary)
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
View full 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 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 0n a 'one off' Regulation 28_ After Inquest Document Template Updated 30/07/2021 May 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 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 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' 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 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. in what way and with with other necessary preparations (in particular ~antiemetic medications) the poisons should be administered: 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 and members of the public:
b. 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 0n a 'one off' Regulation 28_ After Inquest Document Template Updated 30/07/2021 May 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 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 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' 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 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. in what way and with with other necessary preparations (in particular ~antiemetic medications) the poisons should be administered: Sourcing such poisons/chemicals/medications in the UK and abroad_
Responses
Action Taken
The Home Office supports the DHSC's cross-Government Suicide Prevention Strategy (2023-2028) and the DHSC's Concerning Methods Working Group; DSIT has amended the Online Safety Act to make encouraging self-harm a priority offence. (AI summary)
The Home Office supports the DHSC's cross-Government Suicide Prevention Strategy (2023-2028) and the DHSC's Concerning Methods Working Group; DSIT has amended the Online Safety Act to make encouraging self-harm a priority offence. (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.
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.
Sent To
- Home Office
Response Status
Linked 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
Report Sections
Investigation and Inquest
An Investigation into the death commenced on the 8th of Janaruay 2021 and an Inquest heard before me on the Znd of December 2022 that concluded the Investigation. The medical cause of death was determined to be: 1a toxicity I returned a narrative conclusion that Chantelle Williams died as the consequence an unknown quantity of recently self-administered lin circumstances where her intentions remain unclear. 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 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 o the 14th of March 2025
Circumstances of the Death
The deceased had a complex medical history that included previously diagnosed Bi-Polar Affective Disorder, Obsessive-Compulsive Disorder, Emotional Unstable Personality Disorder , Post Traumatic Stress Disorder , Schizoaffective Disorder and recently had been diagnosed to be suffering from Autistic Spectrum Disorder. She had a long history of treatment and care by her Iocal Mental Health Trust that had included phases of both conservative community-based treatment and intensive crisis resolution home based treatment with 8 previous phases of both voluntary and involuntary hospital in-patient treatment and care: Her presentations had included enduring self-harming thoughts and actions with persistent suicidal ideation, previous overdose, impulsivity and emotional dysregulation, and auditory, visual and olfactory hallucination with pseudo-hallucinations within psychotic relapse phases that were diagnosed to be both trauma-induced and associated as a manifestation of her Regulation 28 _ After Inquest Document Template Updated 30/07/2021 being obsessive-compulsive disorder_ The deceased had been in receipt of regular depot anti-psychotic medication. Following her acquiring a quantity of ffrom an internet-based source, she had deliberately ingested a significant, but non-fatal dose on the basis of her using this substance as a form of self-harm in October 2019 culminating in her voluntary informal admission to the Keats Ward of the Meadowbrook Unit of Salford Royal Hospital, Stott Lane, Salford on the 26th of November 2019 where she received ongoing active care, supervision, treatment and monitoring_ Had the deceased sought to be discharged or attempted to leave without clinical approval, it is likely that she would have been detained pursuant to the provisions of the Mental Health Act 1983 because of her assessed high risk of self-harm In February 2020, the deceased had acquired a further quantity ofl whilst on ward and self-ingested a small quantity by reason of an act of self-harm, informing healthcare staff of her actions resulting in medical intervention: multidisciplinary team review meeting interpreted that she was using such overdoses as a method of communicating her ongoing distress Healthcare staff were aware of the deceased's ongoing possession of and the high risk of self-harm with significant risk of deliberate or inadvertent overdose and her presumed or known possession of was managed conservatively by reason of the deceased's status as a voluntary inpatient who had been continually assessed to have capacity. On the 29th of 2020 at approximately 6.45am the deceased was observed in her room on Keats Ward in a collapsed, unresponsive and cyanosed condition. She was being observed hourly and had last been seen alive at about 6am. An immediate 'crash call' was made but she failed to respond to attempted resuscitation and was verified as dead at 7.20am that morning: Post-mortem samples from the deceased revealed the presence of fatally toxic levels of both_ land likely from single batch of (the deceased had previously sourced, retained and hidden: The evidence does not establish the precise quantity or time she ingested the but was analysed to be at levels that would rapidly, within minutes, precipitate unconsciousness, hypoxia and cardio-respiratory failure. The deceased had, incidentally, been properly prescribed promethazine sedating antihistamine to assist her sleep, that would also have produced an antiemetic effect. Police recovered no note or evidence of her intentions and were able to establish no suspicious circumstances or third-party involvement:
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. 1, 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_
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