Surrey coroner calls for poisonous substances to be regulated

A coroner has called on government departments to act and take ownership of suicide risk from poisenous substances after a 22-year-old woman took her own life.

Hannah Aitken died on September 14, 2023, at her supported living accommodation in Caterham after taking a poisonous substance she bought online from abroad.

Anna Loxton, Assistant Coroner for Surrey, said there is an “ongoing concern” with the availability of the poison and there is a need for government departments to monitor and assess these risks. At the inquest’s conclusion on November 7, Coroner Loxton decided to send a Prevention of Future Deaths (PFD) report to the Home Office and the Department of Health. She said there was a “lack of clarity” of which government department is “best placed” to help the general public.

At the time of her death, Ms Aitken was living in a flat in Caterham provided by Brookhaven Care, a specialist housing association for people with autism. She was receiving 24/7 care from support staff and was also receiving mental health care from Surrey and Borders Partnership NHS Foundation Trust (SABP).

The inquest heard how Ms Aitken had struggled with her mental health since the age of 12, having a difficult transition to secondary school. In 2017, she was admitted as an inpatient to a psychiatric hospital where she was diagnosed as having anorexia nervosa, and then later diagnosed with autism.

Ms Aitken was in and out of seven inpatient hospitals in five years, often far away from Surrey and her loved ones. The inquest was told Ms Aitken also had a troubled history of engaging in mental health services and had attempted suicide on a few occasions.

Ms Aitken was under a Community Treatment Order (CTO), meaning she had to take her medication and engage with mental health professionals otherwise she would be recalled to hospital.

Shortly before her death, Ms Aitken refused to engage with mental health professionals, telling them to ‘go away’ or not letting them in the house. The inquest heard how she often refused medication from some of her carers, or delayed taking it.

Yet, Ms Aitken was not recalled to a psychiatric hospital by the agencies involved in her mental health treatment and care at the time. Although one professional raised the alarm that she was deteriorating, it was not deemed to be at crisis point.

In the weeks before her death, Ms Aitken purchased a poisonous substance online, which she took soon after it was delivered on September 14. The care coordinators present did not see when or how the package could have been delivered, and would normally request Ms Aitken to open it in front of them.

The coroner heard evidence from the Home Office there is no regulation of the poisonous substance to address the risk of suicide and self-harm. Instead, The Poisons Act 1972 is focused solely on the prevention of terrorism. The coroner also heard evidence that there is no regulation at all to importing the poison from abroad but is subject to individual company’s discretion.

In their submissions to the inquest, the Aitken family argued that there had been a breach of their daughter’s human rights. Hannah’s father, Pete Aitken, said after the inquest there had been “shocking shortcomings” in the regulation of the poisonous substance which the Home Office knew about since 2020, and that the state had failed to detect and report the risk to life it presented. Expressing grave concern, he said: “Clearly, vulnerable adults like Hannah can still get access to it and use it to end their lives.”

Assistant Coroner Loxton said she could not find that any specific steps that should have been taken by the government to address the risk before Hannah’s death but the “dangerous availability” of the substance is an ongoing concern. She said there is a “small but increasing number of cases of people using the same substance, and that “the state should take notice”.

Coroner Loxton said Ms Aitken was “always at high risk of suicide” with the deterioration of her mental health. She did not find that steps could have been taken by the Home Office to prevent Ms Aitken’s death at the time and recognised the department is actively exploring legislative options.

Leigh Day solicitor representing the family, Caleb Bawdon said: “The Aitken family firmly believe Hannah’s death was avoidable and, had her care and treatment been carried out with a full understanding of her needs, and lessons been learned from previous deaths involving this poisonous substance, that she would still be alive today.”

Mr Bawdon added that the family is calling for urgent action to “avoid a repeat of such tragedies in the future”. He said: “My clients believe this is not good enough – and are calling for the Home Office to take urgent action to introduce regulation to prevent suicide and self-harm from this lethal substance.”

At the conclusion of her inquest, on November 7, Ms Loxton recorded the cause of death to be from autism, ADHD, anxiety and depression. The Aitken family highlighted during the inquest their concern that there was a lack of experience and expertise in caring for their daughter’s complex needs.

A Brookhaven Care spokesperson said: “The Coroner stated in her findings and conclusion that she could not find that the events of 14th September 2023 were foreseeable or preventable by Brookhaven, in terms of Hannah’s presenting condition that day or her ability to order online and take delivery at home of the substance which she then so sadly used to take her own life.” Hannah was assisted by Brookhaven Care to live as independent a life as possible, at home. Although Ms Aitken had round-the-clock support, she was not under one-to-one observation and nor was she meant to.

“Hannah was assisted by Brookhaven Care to live as independent a life as possible, at home. As noted by the Coroner, she was not under one-to-one observations, nor was she meant to be. The Coroner referred to the comprehensive nature of the Support Plan which Brookhaven Care put in place. The Coroner also referred to finding only positive support from Brookhaven Care, noting the evidence that revealed the care, concern and compassion of the Brookhaven staff caring for Hannah, and noting from the documentary evidence their celebration of positive progress in Hannah’s life, reflecting the genuine consideration they had for her welfare.

“All of us at Brookhaven cared deeply for Hannah and were hugely saddened by her tragic death, and we offer our condolences to Hannah’s family and friends.”

Although the coroner found SABP were not at fault during the inquest, the NHS trust decline to comment at this time.

Coroner Loxton decided to send a Prevention of Future Deaths (PFD) report to the Home Office and the Department of Health. A Home Office spokesperson said: “Our thoughts continue to be with the families and friends of Hannah Aitken and those who have sadly lost their life due to this substance. Once received, Ministers will consider the Coroner’s report carefully.”