Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
James Lacey · 29 Nov 2021 · James Adeley, Lancashire & Blackburn with Darwen
“relatively small quantities of can easily be purchased (2) a. is currently a”
judiciary.uk/…/james-lacey-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Jonathan Shaw (25 Apr 2024) · stated timescale: June 2023
“In June 2023, wrote to all Chief Constables, highlighting the need for preparedness in addressing related challenges. Briefing materials were circulated to all UK police and regional suicide prevention leads.”
Stated action 2 · response to Hannah Aitken (14 Nov 2024) · stated timescale: none stated
“The group has worked with businesses, including online suppliers and manufacturers of the substance, to reduce people's ability to purchase it for non-legitimate purposes including suicide, and to raise awareness around safeguarding concerns with businesses where required.”
What recurred
- 25 Apr 2024 · Jonathan Shaw · Catherine McKenna
- 14 Nov 2024 · Hannah Aitken · Anna Loxton · Closely related · confidence 0.90 (high)
- 23 May 2025 · Matthew O'Reilly · Timothy Brennand · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Hannah Aitken · 14 Nov 2024
“[REDACTED] 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.”
Later · Matthew O'Reilly · 23 May 2025
“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”
What happened next
No evidence found either way · stated action 1
“The National Consortium on Preventing Law Enforcement Suicide**TM** (the Consortium) is a group of multidisciplinary experts with a common goal of preventing officer suicide. Convened by the IACP, the Consortium focuses on solutions to emerging challenges and successes of the field in addressing mental health and preventing officer suicide.”
National Consortium on Preventing Law Enforcement Suicide™ · theiacp.org/…/national-consortium-on-preventing-law-enforcement…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 2
“Effective suicide prevention is comprehensive: it requires a combination of efforts that work together to address different aspects of the problem.”
A Comprehensive Approach to Suicide Prevention – Suicide Prevention Resource Center · sprc.org/effective-prevention/comprehensive-approach
No evidence found does not mean the action did not happen.