Dear Coroner Irvine Re: Inquest into the death of Thiago Araujo Prevention of Future Deaths repott am writing further to the inquest for Araujo which was heard on 4* 6th January 2021 ad concluded on Thursday 28 h January- Following the inquest YoU issued a Prevention of Future Deaths report to a number of organisations including the Trust will address the matters of concern raised in this report in turn. On 24th January 2020 Mr Araujo had discharged himself from psychiatric inpatient care; he was to be supervised by the Camden and Islington NHS Foundation Trust crisis team: Mr Araujo failed to engage with the crisis team and following a meeting on 30 January 2020 the crisis team closed Mr Araujo' $ referral: In the course of this closure no arrangements were made to address the risks presented by Mr Araujo. Following the initial 3 days of this inquest the Trust wrote to you to provide some additional assurance around the Serious Incident (SI) investigation report and the recommendations made, which were updated and strengthened in light of the issues raised at the hearing: One of the additional recommendations concerned this matter is as follows Additional Recommendation: service user of the Crisis Team who is being considered for discharge because of non-engagement must be discussed in the Crisis Service Multi- Disciplinary Meeting with senior overview of the decision to discharge. The decision and rationale to discharge because of non-engagement must be clearly communicated to the Youi parnor in CR coio Improvomonl ISLINGTON Ca"entaaal purdr cntelald pezpie InIng In Camden end iuinosdre0 Tdole Tdi E Won Thiago and Anv

NHS community and carers and this must be clearly documented in the clinical notes. When a service user is discharged because of non-engagement the Community Team must update the Crisis and Contingency Plans to ensure the service user and carers are aware of the support available following discharge. This action was due to be completed by the end of February and can confirm that this practice is now in place_ Following Mr Araujo' $ death it has become clear that the closure of his case by the crisis team was not permanent had Mr Araujo or his family approached the crisis team to reopen his case, steps could have been taken to reinstate crisis team support: Mr Araujo' $ family were unaware of this facility: On discharge it is the crisis team' $ standard practice to advise service users that they may re- refer themselves, be re-referred, should the need arise. We can only sincerely apologise to Mr Araujo' $ family if this was not made clear to them in this case. All crisis team staff have been reminded of the need to ensure that this information plus relevant contact details is passed on: This is also covered by the recommendation at point 1, where the updating of crisis and contingency plans is required. Families and corers of potients diagnosed with emotionally unstable personality disorder do not receive support or education upon management of this diognosis from Camden and Islington NHS Foundation Trust; unless the patient hos received for treatment by the personality disorder service: The Trust has a duty to assess carers need for support as part of its responsibilities under the Section 75 Agreement with the Local Authority When the Personality Disorder Service identify a carer who may be in need of support, either at the point of referral, assessment or during the treatment of a patient; a Carers Assessment at the service is offered A Carers Lead is employed to fulfil this role. When the Personality Disorder Service is not directly involved carers are directed to Local Authority services Support for carers Camden & Islington Carers Hub Supporting unpaid carers in Islington: Carers assessments are also carried out by other community teams within the Trust, including the community rehab team,who can support carers to access appropriate support The Trust recognised that a theme in the report was that carers had lost confidence in the teams working with the deceased did not feel their views were taken on board: As a result of this feedback the Trust has revised the action plan with an additional recommendation relevant to carers involvement. To provide assurance that this is consistently happening; the strengthened action plan includes a requirement for community teams to carry out 6 monthly audits, checking that carers are routinely offered an assessment and support plan, and that information, support and psychoeducation are available: Plans will be developed to address any gaps identified as a result of these audits which are now underway within the teams team and been key " and

NHS By 4 February 2020 the Camden and Islington Recovery Team identified an acute risk of suicide in Mr Araujo, faced with his noncompliance with community treatment they considered an admission into inpatient care: No actions were taken to affect this plan: In evidence the community recovery team indicated that 0 factor in their inaction was the knowledge that arranging a section 135 Mental Health Act 1983 warrant and assessment would take two weeks Such an assessment requires actions from an approved mental health practitioner from the local authority, two section 12 Mental Health Act approved doctors, the assistance of the Metropolitan police and the local magistrates court to secure a warrant delay of 14 days in securing 0 Mental Health Act assessment is in view unacceptable The AMHP service, which coordinates and carries out assessments under the Mental Health Act; is a local authority service, although physically based on Trust premises The Trust has liaised with our local authority partners in regard to this important issue ad we can report as follows: The average wait for a community assessment at the moment is around 14 days: February 2020 when the incident took place the average wait time was closer to 18 days, so we are seeing some improvement but acknowledge further is required. This issue is part of our CQC action plan and ongoing monitoring is in place as part ofthis via our Mental Health Law Committee Reducing average time There have been a number of actions by the AMHP service and the police to reduce wait time over the last year. Very often delays have been due to police availability/capacity in providing a time slot when are able to attend in support of an assessment: The police now have a permanent team in their mental health department ad the size of this team been maintained. also have a more robust management structure so we have a clear reporting mechanism if we have concerns This has enabled the team to continue to support us throughout the year. The AMHP team is responsive to the challenges of the Covid 19 pandemic, including the management of staff absence, to ensure all resources across the boroughs are used to maximum effectiveness and response to service user needs: In mid-2020 both boroughs made additional investment in their staffing: Prioritisation Although the average wait time for a community assessment is 14 response is managed with individual risk assessment and prioritised response At the point of referral for a Mental Health Act assessment the referral is discussed with the referrer and an understanding of the risks and urgency of the assessment are established. Any assessments my regard they has Thev days,

[HS with significant risks are flagged to the duty manager and service manager and an early conversation is had with the police- It is established practice to communicate with the referrer so that the AMHP team are aware of and can respond to changes in the service user' $ level of assessed risk The inquest has highlighted the need to ensure Trust services are aware of the AMHP service' $ capacity to prioritise waiting times and the AMHP service' $ commitment to ongoing information sharing with referrers: In the days leading to Mr Araujo'$ death his family became aware that he had made an online purchase of sodium nitrite which was to be delivered to his father s home. Despite these issues with Camden and Islington NHS Trust, the Metropolitan police and employees of the Post Office there appeared to be no process available to the family to escalate their concerns to prevent delivery of this package: It was apparent from the evidence given at the inquest that at the time of this incident Trust staff were unsure how to respond to this situation and what actions if any were available to them. The Trust has since sought advice from its legal team ad guidance to staff on this issue, as well as reiteration of previous advice around access to means to self-harm generally; has been circulated across the organisation. The legal advice we have received is that the Royal Mail do potentially have powers to intercept and destroy packages containing items which are either prohibited or restricted from being sent in the mail. Therefore, as part ofthe response to concerns of this nature, teams should consider reporting any concerns about potentially dangerous packa_ to the Royal Mail (via the local sorting office) and also to the police and must ensure that discussions and actions taken are documented in the clinical records It would be very helpful in informing our actions going forward, if we can be provided with a copy of the Royal Mail' $ response to the PFD as we are keen to work with them in regard to these challenging situations that my response clarifies the position and provides you with the necessary reassurance . If you need any further information, please do not hesitate to contact me.

Confidential

1

Response to Assistant Coroner Irvine’s Prevention of Future Deaths Report dated 29th January 2021 relating to the death of Thiago Araujo (‘the Report’) Introduction
1. Royal Mail Group Limited (‘RMG’) operates the UK mail system. It is the universal service provider obligated by law to deliver mail once per day, Monday to Saturday, to every Mainland UK postal address.

2. The Report refers to the Post Office. Post Office Limited is a wholly separate legal entity. The two companies were separated in 2012 and now operate independently. Therefore, RMG can make no comment on behalf of the Post Office. The Inviolability of the Mail
3. Section 104 of the Postal Services Act 2000 (‘PSA’) states that whilst in the course of transmission by post, a letter, packet, parcel or mail bag and/or their contents are immune from “examination, seizure or detention as it would have if it were the property of the Crown.” Therefore, a postal packet is inviolable whilst it is in the mail system i.e. from the point it is posted until it is delivered.

4. It is a criminal offence for a postal operator to intentionally delay or open a postal packet, contrary to his duty and without reasonable excuse, in the course of its transmission by post (Section 83(1) PSA).

5. It is also an offence for a person, intentionally and without lawful authority, to intercept any communication in course of its transmission by post (section 3(1)(a(iii) of the Investigatory Powers Act 2016(‘IPA’)).

6. Therefore, RMG staff cannot delay, open or otherwise interfere with postal packets unless permitted by law. Lawful Interception
7. In the circumstances described in the Report, there are only two routes to lawfully intercept postal packets after they are posted and before they are delivered.

Confidential

2

Option 1 – IPA powers
8. The Police can obtain a targeted interception warrant, a mutual assistance warrant or a bulk interception warrant pursuant to Section 6(1) of the IPA. The communication can also be intercepted pursuant to Section 44 of IPA:

(i) if the sender and recipient consent, or (ii) either the sender or the recipient consents and a directed surveillance authority is in force pursuant to Part 2 of the Regulation of Investigatory Powers Act 2000.

RMG is committed to co-operating with the Police and other law enforcement agencies and will always provide assistance to them, as far as the law permits.

9. RMG will also assist the Police by undertaking a controlled delivery i.e. delivering an item with Police Officers in close proximity. This allows the Police to enter the premises immediately after delivery and seize the postal packet using their powers under the Police and Criminal Evidence Act 1984. Option 2 - RMG’s Terms and Conditions
10. Section 83(3) of the PSA states that no offence of opening or delaying the mail is committed if the opening or delay is done in accordance with the terms and conditions applicable to the transmission of the postal packet by post. There are similar provisions within the IPA which make interception, for the purposes of the provision and operation of the postal service, lawful.

11. RMG’s terms and conditions clearly state that certain items cannot be carried through the network.

A list of these prohibited items can be found at

12. Certain items are restricted i.e. they may be carried but only if the sender complies with certain conditions. Restricted items, such as lithium batteries, paint and kitchen knives will only be intercepted if the postal packet does not comply with the conditions of carriage (usually how they are packaged).

Confidential

3

13. Training and written guidance is available to RMG staff in relation to the handling of prohibited and restricted items. RMG also operates a Security Helpdesk which staff can contact to report any security or safety issue or seek advice.

14. Where RMG staff receive information, or have cause to suspect, that a postal packet contains a prohibited item which is also illegal (such as controlled drugs, automatic firearms or child pornography) the Police will be contacted (unless the Police are the source of the information). The packet will then be opened and inspected by the Police. The Police will assess the legality of the item and will inform the RMG staff of their opinion and any other information available. If the RMG staff member is satisfied the item is illegal, and therefore prohibited, it will be handed to the Police. As above, we will assist the police in performing a controlled delivery, if requested. If RMG staff are unsure of what action to take they can always contact the Security Helpdesk for advice.

15. If RMG staff receive information, or have cause to suspect, that a postal packet contains a prohibited item which is not illegal per se (such as flammable gas, pesticides or live animals) our staff may open and inspect the contents to ascertain whether the item is prohibited. Where our staff are sure the item is prohibited, RMG has a wide discretion as to the disposal of that item thereafter.

16. However, our staff must be sure the item is prohibited. RMG operates the national mail system. Our primary purpose is to receive, process and deliver postal packets. This includes handling many items which are not dangerous per se but could be used to cause harm. The purpose to which an item, which is not prohibited, might be put is not a consideration for the national postal operator. We must also be careful not to expose our staff to criminal liability by allowing or encouraging them to intercept mail unless it is lawful to do so.

17. Therefore, before any postal packet, suspected to contain prohibited items which are not illegal, is opened, delivery office staff should make contact with the Security Helpdesk for an assessment to be made as to whether interception is lawful. Security Helpdesk staff are provided with written guidance and a process to follow to determine the issue and record the reasons for the decision made. If the item is assessed as prohibited, it will be disposed of appropriately.

Confidential

4

Conclusion
18. We are satisfied that, within the restrictions placed upon us by law, our processes for the handling of restricted and prohibited items within the mail system are adequate and appropriate. Therefore, we do not intend to take any action in response to the Report.

19. No specific information has been presented establishing that RMG was asked to intercept, delay or otherwise divert the postal packet concerned. If there is evidence that information was passed to RMG staff and no action was taken, we would be grateful to receive details of what information was passed to our staff and in what circumstances. We will then conduct further enquires.

Senior Legal Advisor Royal Mail Legal

12th March 2021

METROPOLITAN POLICE PROFESSIONALISM HQ Assistant Coroner Mr Graeme Irvine Poplar Coroners Court Deputy Assistant Commissioner 127 Poplar High Street New Scotland Yard Poplar Victoria Embankment London London E14 OAE SWIA 2JL Email= Tel: Our Ref: Date: 8th April 2021 DecrHz Iruine am responding on behalf of the Commissioner of Police of the Metropolis to your Regulation 28 Report to Prevent Future Deaths, dated 29th January 2021. Your report was sent following the conclusion of the Inquest into the tragic death of Thiago Araujo who died on 5th February
2020. The Metropolitan Police Service's (MPS) Directorate of Professional Standards' Specialist Investigation Unit (DPS SIU) conducted an investigation into police contact with Mr Araujo to his death on 5th February 2020. Death or Serious Injury (DSI) report was completed following a determination by the Independent Office for Police Complaints (IOPC) that this investigation should be conducted by the MPS: The investigation found that Mr Thiago Araujo had been suffering from deteriorating mental health and had been reported missing by his father on 5th February 2020. Mr Araujo was believed to be in possession of sodium nitrate which he intended to harm himself with: Mr Aruajo was declared high-risk missing person by the MPS and an active search was instigated: Sadly, Mr Thiago was found deceased at a family address approximately one hour after initial missing person report was recorded. The MPS concluded that no officers had breached any policy guidance or legislation and at the time no individual or organisational learning opportunities were identified. The MPS has acknowledged and reviewed all six matters of concern that you have raised and has sought to address matters five (5) and six (6) as,the appropriate lead agency: The response to these two matters is as follows: In evidence the community recovery team indicated that a factor in their inaction was the knowledge that arranging section 135 mental health act 1983 warrant and assessment would take two weeks. Such an assessment requires actions by an approved mental health practitioner from the local authority, two section 12 mental health act approved doctors, the assistance of the Metropolitan police and the local Magistrates Court to secure a warrant_ delay of 14 days in securing a mental health act assessment is in my opinion unacceptable: prior the

Any delay in securing a Mental Health Act warrant and subsequent assessment would be for the relevant Mental Health Trust to respond to in detail, as the warrant application process is not conducted by the MPS. However, believe it would assist HM Coroner, by explaining the processes in place for securing police assistance in such matters_ The Mental Health Act 1983 (Codes of Practice), stipulate that responsibilities for arranging Mental Health Act Assessments Iie with Local Authorities, who must ensure there are sufficient Approved Mental Health Professionals (AMHP) available to carry out their roles under the Act This includes assessing patients to decide whether an application for detention should be made_ There are a number of elements the AMHP should arrange before request is made to the police to conduct a Mental Health Act Assessment (MHAA): A request for police attendance is organised by the co-ordinating AMHP service submitting a Form 435A ('Requesting Police Help with Mental Health Act Assessment') 'via the MPS Secure Forms Portal: Prior to accessing the form, the AMHP is provided with details of the information required to complete the form, ensuring sufficient detail is given to assist the MPS with their request: The information shared by the AMHP within the Form 435A enables the police to complete the necessary risk assessments and allocate resources. Following an escalation of risk by either the AMHP or the police, the matter can be escalated for a more urgent response provided by an Emergency Response Police Team (ERPT) Where the AMHP has reason to believe that someone is in imminent risk of endangering themselves or others, or have an immediate concern for the individual's welfare , are informed to telephone 999 immediately. Where an immediate risk has not been identified, the AMHP responds to two triage questions confirming whether a warrant has been obtained and where the location for the assessment is_ The AMHP is then requested to provide dates for the assessment to take place_ The police from the relevant geographical area will review the request and search police indices for further information and intelligence about the individual to be assessed, and the location of the assessment Within 48 hours of receipt of the request, the MPS will then contact the AMHP with decision about police attendance. The assessment date and time is discussed and agreed with the AMHP depending on the information contained within the risk assessment. However, it is also dependent on the AMHP ensuring that all other elements are in place which could impact on the timeliness of the date of the MHAA The risk of harm will always be taken into account when assessing and prioritising these cases_ The current MPS policies and procedures governing the framework, operational and tactical guidance for Police Officers and Staff, were updated in May 2020. The guidance specifically assists Basic Command Unit Operations' Room Staff involved in the preparation and planning of warrants under section 135(1) and 135(2) of the Mental Health Act with responding to AMHP requests_ In the leading to Mr Araujo's death his family became aware that he had made an online purchase of sodium nitrite which was to be delivered to his father's home Despite raising these issues with Camden and Islington NHS Trust, the Metropolitan Police and employees of the post office there appeared to be no process available to the family to escalate their concerns to prevent delivery of this package: The interception of communications (including postal services) is governed, in general terms _ by the Investigatory Powers Act 2016, supported by the Codes of Practice associated with this In summary, an authority obtained under this Act is only granted by the Secretary of State in circumstances defined by Code
4.10, and is necessarily limited. to such matters as in the interests of national security and preventing or detecting serious crime. It is therefore they they days

regrettable that there would be no lawful powers by which the MPS would have been able to intercept Mr Araujo's package. The use of this and other lawful; unregulated substances and suicide kits to complete suicide is an issue that is being monitored nationally by police forces, the Home Office and the National Confidential Inquiry into Suicide and Homicide (NCISH): The MPS has direct communication with the NCISH on a frequent basis. Reducing access to 'means is a component in the prevention of suicide. Unfortunately, given the availability and accessibility of many other potentially effective methods, restricting access is likely to have limited success. Existing efforts to reduce the propensity of suicide ideation and suicidal behaviours are often preferable Additional Information The MPS is committed to learning from deaths by suicide. A dedicated team is developing Suicide Prevention Policy Document and Toolkit The publication of this policy is step in developing our CO-ordinated strategy to suicide prevention: The policy intends to draw together information on suicide prevention, support services, risk indicators, contacts and best practice_ A draft external Suicide Prevention Policy is due to be submitted through the MPS's internal policy development process. The policy will be accompanied by a toolkit providing easy to access guidance and advice, from signposting support services to identifying key partners. An investigative standards document; which forms part of the toolkit, is under development and is designed as an easy to follow points to consider' document for police first responders This will enhance knowledge and understanding across the entire MPS and build on the additional guidance that is already used by some teams where death by suicide is considered higher risk: The MPS Suicide Prevention Team is committed to improving the training and guidance available to all officers and staff within the MPS, In Conclusion wish to express my condolences to the family of Mr Araujo. The MPS is committed to supporting all vulnerable individuals and working with other professionals to assist them in getting the appropriate where necessary: The measures described above allow the MPS to focus on ensuring the appropriate exchange of information takes place to provide the MPS with greater awareness of factors indicating a risk of suicide_ trust this provides the reassurance that the MPS has considered the matters of concern you have raised_ Please do not hesitate in contacting me should you have any queries.

Dear Mr Irvine

Thank you for your letter of 29 January 2021 about the death of Thiago Araujo. I am responding as Minister with responsibility for mental health and suicide prevention and I am grateful for the additional time in which to do so.

I would first like to say how deeply saddened I was to read of the circumstances of Mr Araujo’s death and I offer my most heartfelt condolences to his family and loved ones at this difficult time.

In relation to the concerns you raise about the use of Section 135(1) of the Mental Health Act, it is not clear from your report whether the delay professionals expected lay in the magistrate issuing a Section 135(1) warrant; in securing an approved mental health practitioner and a doctor to be present when the officer actions the warrant; or in securing two doctors to carry out an assessment under the Act after the patient has been taken to hospital. However, we expect local organisations, including the police, local authority services, and the NHS, to have robust systems and agreements in place to ensure these actions are carried out swiftly.

I am aware that the Camden and Islington NHS Foundation Trust has provided a response to your report in which it has explained the action that is being taken to improve the responsiveness of the assessment process involving the police and Approved Mental Health Practitioners. I have also been advised that the Trust has taken further learnings from the findings of your investigation, in particular, in relation to decision making and communication with carers when patients are discharged from the Crisis service due to non-engagement; as well as greater assurance that carers and families are routinely being offered the support and information they need.

It is essential that the Trust and local partners take action to learn from Mr Araujo’s death to improve the safety and quality of care locally.

My officials have brought your report to the attention of the CQC which, as you will know, is the independent regulator for care quality in England responsible for monitoring and inspecting health and care services against the fundamental standards of quality and

safety, with the ability to take action where providers of services are not meeting their legal obligations.

I would like to assure you that we are taking action nationally to ensure that people with severe mental illnesses and people in crisis can access timely support.

We remain committed to expanding and transforming mental health services in England. This commitment is backed by an additional £2.3 billion by 2023/24 through the NHS Long Term Plan. This funding will ensure that at least 370,000 adults with severe mental illness have greater choice and control over their care and are supported to live well in their communities by 2023/24.

On the wider matters of your report, you may wish to note that we are working with a broad range of stakeholders to tackle emerging suicide methods, including the use of chemicals such as Mr Araujo took, and a process has been established with a range of stakeholders and across Government to rapidly flag emerging methods and take actions through a multi-agency approach. This includes but is not limited to, limiting access to the method, reducing or removing material that promotes its use as a method of suicide, and providing clearer warnings of risk.

With specific regard to the chemical that Mr Araujo used, officials have met other Government departments and bodies, academic experts on suicide prevention and self- harm, and third sector stakeholders, to look at how to tackle the use of this and similar chemicals in suicides.

Officials are informed through these meetings that the chemical used in this case is covered by existing guidance from the Home Office on the sale of explosives precursors and poisons. The Home Office regularly engages with suppliers of such chemicals to provide detailed guidance in relation to any additional safeguarding steps they may wish to take. Generally, online marketplaces maintain their own policies on prohibited items, many of which will include a prohibition on the sale of poisons. It is the seller’s obligation to check that items they are listing are permitted by their own policies and to take any action where it is appropriate.

Significant progress has already been made on limiting the availability of the chemical used in this case, for example, in tackling supply of the chemical for non-industrial use. A chemicals supplier is working with Government to alert us of suppliers of this chemical on a number of large, online retail platforms. I am aware also that eBay has decided to prohibit globally the sale of this chemical after receiving a report of its potential use as a suicide method, and it has improved its block filter algorithms to ensure there are no similar listings.

In addition to work within Government, Samaritans are working regularly with the media to educate and improve how incidents of suicide are reported. This includes working with the media on how it reports novel suicide and, in this case, the importance of omitting details that raise awareness of suicide methods. We are aware also that there are websites that promote, or provide information on, suicide methods. The Department for Digital, Culture, Media and Sport (DCMS) published its

Online Harms White Paper1, which set out a range of legislative and non-legislative measures detailing how the Government is planning to tackle online harms, including harmful materials on self-harm and suicide.

On 15 December 2020, DCMS published its response to the White Paper consultation, setting out how the proposed legal duty of care on online companies will work in practice and gives them new responsibilities towards their users. DCMS also announced that the Government has asked the Law Commission to examine how criminal law will address the encouragement, assistance and incitement of self-harm.

NADINE DORRIES

MINISTER OF STATE FOR PATIENT SAFETY, SUICIDE PREVENTION AND MENTAL HEALTH

1 https://www.gov.uk/government/consultations/online-harms-white-paper

Dear Ms Mazepina,

Thank you for your email of 7 April to the Home Office relating to the inquest into the death of Mr Thiago Araujo following the consumption of sodium nitrite. I am replying on behalf of the Security Minister who has taken a temporary leave of absence for curative surgery and I am sorry for the delay in responding to your email.

I have carefully noted the contents of your prevention of future deaths report and I recognise the need for continued awareness raising of the controls around sodium nitrite and the obligations to online marketplaces when selling this substance.

Sodium nitrite has legitimate uses as a food preservative, but because of its toxicity it is a reportable poison under the Poisons Act 1972. This means that it is generally available to members of the public without the need for a license, but sellers, including online sellers, must take appropriate steps to assess if there are reasonable grounds for suspicion before accepting a transaction. They are obliged to make suspicious transaction reports where they have grounds to believe that the sale is for an illicit use.

The Home Office regularly engages with suppliers to help them meet their requirements under the Poisons Act and provide detailed guidance in relation to any additional safeguarding steps they may wish to take. Generally online marketplaces maintain their own policies on prohibited items, many of which will include a prohibition on the sale of poisons. It is the seller’s obligation to check that items they are listing are permitted by their own policies and to take any action where it is appropriate.

I strongly believe that we must do as much as possible to safeguard those who may be vulnerable to harmful sales of poisons including sodium nitrite. For that reason, I can confirm that the Home Office is aiming to establish a consultation this summer on possible amendments to the Poisons Act, which will include more obligations on online marketplaces including reporting suspicious transactions within 24 hours.

We will also continue to work with suppliers to ensure they recognise their obligations under the Poisons Act for sodium nitrite.

Baroness Williams of Trafford