17 April 2024

This is a press release by Saunders Law, reshared by INQUEST

Before HM Assistant Coroner Michael Wall
Nottingham Coroner’s Court 
Hearing 24 January - 6 February 2024 (10 days)
Prevention of Future Deaths Report 29 February 2024

Daniel Tucker took his own life within hours of release from – but whilst still formally detained by – Highbury Hospital. The inquest jury concluded on 6 February 2024, that multiple failings admitted by the hospital Trust (Nottinghamshire Healthcare NHS Foundation Trust (‘NHCT’)), contributed to Dan’s death (link to full article on inquest conclusion here). 

Now the Coroner has raised 5 serious concerns about the ongoing risk of future deaths described in detail further below, directed to the following:

  • Nottinghamshire Healthcare NHS Foundation Trust – 3 concerns raised;
  • NHS England and Secretary of State for Health and Social Care – regarding categorisation of emergency calls;
  • OFCOM and Secretary of State for Health and Social Care – arising from the ease of access of the public to a pro-suicide forum online;

Dan was just 24 when he died. He was a much loved brother and son, who was kind, generous, intelligent and thoughtful. He had a love for animals, and loyalty for those closest to him.

He died on 22 April 2022, within hours of his release home from Redwood 1 ward at NHCT-run Highbury Hospital, after ingesting a highly toxic substance he had purchased from a controversial website based in Canada, less than a month earlier.

A person responsible for the website and providing the substance is currently under criminal investigation in Canada.

Recent news confirms another supplier of the same substance has been found operating from the Ukraine, and who is believed to have been using the same controversial suicide forum utilised by Dan, to target vulnerable users. So far it is understood his sales of the substance have been linked with 130 deaths in the UK alone.

Summary of the concerns included in the Regulation 28 report 

Addressed to NHCT:

1) A continuing practice/culture of minimising the importance of a ward specific risk assessment and care plan;

  •  The Coroner states: “I am concerned that, notwithstanding the existence of a clear, appropriate policy and significant commendable actions by the Trust since Daniel’s death to address this issue, there remain clinical and nursing staff who do not fully recognise or accept the importance of completing and utilising the required risk assessment and care plan”.
  • In Dan’s case, “an experienced ward nurse and two psychiatrists (a consultant and a registrar) involved in Dan’s care seemed to minimise the practical importance of the required process and documentation, the latter both suggesting they would not routinely consult it”.

2) Inadequate system of allocating a named nurse to patients and recording the same;

  • The Coroner states: “I am concerned that, notwithstanding the existence of a clear, appropriate policy requiring the same, the current system of allocating a named nurse and ensuring patients receive regular and effective 1:1 sessions with them are inadequate. I am also concerned that no record is kept of the named nurse appointed to each patient, thus (as in this case) hindering any investigation where issue around the role and actions of that person arises”.
  • “…The General Manager assured me that he has already requested an urgent review of the system, but he was unable to provide any further information upon conclusion of the inquest as to what further action, if any, is proposed”.

3) Inadequate skills/knowledge/training on how to encourage patients to engage;

  • The Coroner states: “I am concerned that clinical, nursing and/or support staff may not currently have sufficient skills or knowledge in dealing with patients who appear unable or unwilling to engage with staff and/or treatment”.
  • "A psychiatrist not involved in Dan’s care gave evidence about the advice he would have given to colleagues on how to seek to assist a patient who, like Dan, was unwilling or unable to engage with staff: first, identify the likely reasons for the patient’s lack of engagement; second, having regard to those reasons, develop plans and strategies to address the specific barriers identified.
  • “I heard little evidence that either of these steps was followed by any of the staff involved in Dan’s care. One barrier was identified (his previous negative experiences on the ward and wish to be transferred to another ward or hospital) but seemingly forgotten after an initial transfer request to the Bed Management team, which was not then followed up. Even with the benefit of hindsight, the doctors, nurses and healthcare assistants involved in Dan’s care seemed unable to offer any insight into the reasons for his difficulties engaging beyond his diagnosis of EUPD or articulate any strategies or techniques that might have helped him overcome them”.

Addressed to the Secretary of State for Health and Social Care & NHS England:

4)    Concern that confirmed ingestion of the toxic substance during a 999 call does not trigger a category 1 response from the Ambulance Service.

  • In Dan’s case, the first of two 999 calls (at 20:30 on 22 April 2022) was correctly graded as a category 2 response. The 999 call handler was informed he had taken the toxic substance, but that he remained conscious and awake.
  • 14 minutes later, at 20:53, Dan collapsed. The second 999 call was correctly graded as requiring a category 1 response, as he was by that time unconscious with agonal breathing. The ambulance crew arrived at 21:04.
  • Dan went into cardiac arrest at 21:24, at which point it was considered no longer feasible to follow the plan to administer the drugs in an attempt to counter the impact of taking the toxic substance.
  • A consultant toxicologist gave evidence at Dan’s inquest, that even in very small quantities, the toxic substance is lethal; it is a potent poison, the acute toxic effects of which can be rapid (as short as 20 minutes after ingestion depending on the dose taken) and can quickly become irreversible.
  • It is also understood to be an increasingly common means of suicide.
  • As such, the Coroner’s concern is that in “almost any case involving the ingestion of [the toxic substance, it] is likely to be a time critical life-threatening event. Yet it does not currently fall within that category for the purposes of grading 999 calls, unless the patient is unconscious or not breathing”. As such, he believes “there is a risk that other deaths will occur if ingestion of [the toxic substance] continues to require a category 2 response”.

Addressed to the Secretary of State for Health and Social Care and the Chief Executive of OFCOM:

5)    Continuing accessibility of the pro suicide web-forum utilised by Dan (through which he came across the details of the seller of the toxic substance he took).

  • “Through that forum [Dan] was able to engage in discussions with other pro-suicide members and obtain information on the means of taking his own life and on how and where to source those means.
  • "Notwithstanding the provisions of the Online Safety Act 2023, and apparent attempts to block access to the website, I heard evidence that it remains easily accessible to vulnerable people in the UK. I am concerned that further deaths will occur while this remains the case”.

The report has been sent to the following other Interested Persons from the inquest:

  1. East Midlands Ambulance Service
  2. Care Quality Commission (who are conducting the ‘special review’ into NHCT recently ordered by the government’s Health and Social Care Secretary).

Responses to the PFD Report

Those to whom the Coroner’s concerns have been directed, now have until 27 April 2024 to respond, detailing the action taken / to be taken, whether in response to the report or otherwise, and the timetable for it. If they propose to take no action, they must explain why. 

Concerns not included in the PFD report

In deciding which of the concerns raised on behalf of the family should be included in the PFD report, the Coroner noted the following (the following is not a complete list of the concerns raised on behalf of the family):

Regarding the concern that the existing process for obtaining and considering information from carers and family prior to any final decision to discharge a patient, gives rise to a risk of future deaths

  • One of the several admissions of the Trust in this inquest was that “There was a failure by the ward staff to engage adequately with Dan’s family and/or carers either during his admission on Redwood 1 and/or at the point of discharge”.
  • The Trust confirmed in evidence that since Dan’s death, they have introduced a Carer Peer Support Worker role (‘CPSW’) on all in-patient areas; this is a full-time post dedicated to the support of patients on the ward; including liaison with family members and loved ones on behalf of the patient. The evidence was that this role is a “game changer”.
  • Taking all of the evidence together, including the evidence that family members and carers are now routinely invited to ward rounds, the Coroner did not believe this issue to be a continuing matter of concern.

Regarding the concern that observation logs were not being accurately completed

  • The Coroner referred to his ‘deep concern’ about the discrepancies identified within the observation logs in Dan’s case (and it is of note that the Trust confirmed during Dan’s inquest, that criminal investigations into some staff members are ongoing in connection with the practice of observations (physical checks carried out on patients primarily aimed to ensure their and others’ safety and well being).
  • However, the Coroner heard evidence from the Trust that significant steps have already been taken to address the issues. As such the Coroner was satisfied his duty to report was not triggered on that issue.

Regarding the ease of availability of the toxic substance taken by Dan

  • The Coroner is aware that there is ongoing coordinated action taking place across government to tackle emerging methods of suicide. The Department for Health and Social Care have confirmed: “DHSC leads a cross-government and cross-sector group that has been established specifically to rapidly identify, and proactively tackle, emerging methods of suicide. This involves close working across government and with academics, the voluntary sector, police, local government, coroners, local suicide prevention leads, ONS and the NHS to ensure we are taking rapid and targeted action to address these methods.
  • Through this group’s close working, there are currently over 30 live actions and interventions that collectively are:
    • reducing public access to methods, both nationally and internationally, including by reducing the sale and importation of methods where appropriate
    • reducing references to, and limiting awareness of, emerging methods, including by tackling online content and working with the media to ensure responsible reporting. This includes exploring further opportunities to address online harms including harmful content shared in pro-suicide websites and forums
    • working with big business, including online suppliers and manufacturers of the substance, with major online suppliers since removing the sale of this substance in its pure form
    • monitoring data and trends to inform rapid and targeted responses, improving the data we collect, and how that information is best shared to inform responses.”
  • Recent changes have been made to the Poisons Act to address the ease of availability of the relevant substance online. “From 1 October 2023 businesses supplying regulated and reportable substances to another business must inform them that the products they are purchasing are regulated or reportable under the Poisons Act 1972.… Online marketplaces have new obligations to take all reasonably practicable measures to provide information to any supplier who uses the online marketplace to sell regulated or reportable substances about their obligations and to identify and report any suspicious transactions.”
  • In conclusion, the Coroner was satisfied that the Government has taken and is taking significant and wide-ranging action to combat the issue of ease of availability of the toxic substance.

Regarding most ambulance services not currently carrying a substance which can counter the effects of taking the toxic substance; and, lack of training for paramedics on poisoning caused by the toxic substance

  • The evidence in this inquest was that there are barriers to ambulance crew carrying the counter-acting substance (not deemed to be an antidote), including that the decision to administer the same can only be taken following observations, requiring equipment which is typically only available in a hospital setting.
  • The Coroner stated however, that that is not to say that the issue requires no further consideration within the ambulance service. The evidence was that the issue has been brought to the attention of NARU and NASMeD, and that work is ongoing in that regard.
  • Further, the Coroner heard evidence that EMAS are gathering more evidence before a local (EMAS) decision can be made as to having a concurrent service with West Midlands Ambulance Service (WMAS), whereby the counter-acting drug can be administered by specialist ambulance crew outside the hospital setting.
  • The critical factor as the Coroner sees it, is the speed at which the patient receives appropriate medical treatment, hence the Coroner has reported on the concern as to how 999 calls are categorised as far as the toxic substance is concerned.
  • As for training of paramedics, the Coroner concluded that he had not heard sufficient evidence such that, had paramedics treating Dan had specific training for treating patients who have ingested the specific toxic substance, there would have been any difference to the outcome in his case. Regardless of the lack of training, the paramedics had made an appropriate and prompt plan for Dan’s treatment. The Coroner concluded therefore, that while the toxic substance is increasingly prevalent, it does not follow that future deaths will occur unless all paramedics receive specific training on it.  Nevertheless, EMAS sought to make it clear that they are committed to raising awareness of the substance nationally and within their service.

Dan’s family said: “We would like to thank the Coroner for his investigation and for issuing the prevention of future deaths report. It has been shocking to say the least to find that these reports about this dangerous substance have been submitted since at least 2020 and very little, if anything, has changed. We can only hope that the government and NHS trusts listen and make meaningful change now.

Regarding Highbury hospital, we found the evidence that we heard about the treatment, or lack of treatment, that Dan received during his last admission to Redwood 1 ward at Highbury hospital, shocking and appalling. To think that Dan received such treatment, and that, more than likely, other vulnerable adults have too, has only added to our grief. The cavalier attitude of, in particular, senior doctors to the procedure, process and law that is designed to protect patients is outrageous.  Our own research suggests that the same failings are often repeated time and again, even where PFD reports are made. We can only hope that this time, the vital changes needed are made.”

Clare Evans, Saunders Law, said: “This inquest has shown the importance of looking at the wider circumstances leading to deaths such as Dan’s. Had this not been an Article 2 inquest, it is unlikely that the Coroner (or any Coroner) would have investigated in any real depth, how Dan came by the substance used in his untimely, tragic death. The investigation into this is significant, in that it ultimately gives rise to an opportunity to save other young lives, by learning lessons. 

Through this inquest, we also heard evidence that the substance used in ending Dan’s life can be toxic even in very small quantities, leading one senior witness at the Trust to conclude that “it appears to me to be a no return chemical”. The toxicologist’s evidence, however, was that it is only likely to be irreversible if appropriate treatment is not administered quickly. It is clearly, therefore, imperative that the emergency response to ingestion of the substance is re-categorised as a matter of urgency, so that other such deaths can be avoided”.



For all media inquiries, please contact: Clare Evans at [email protected] or 020 7632 4300.

Daniel’s family were represented by Inquest Lawyers Group members Clare Evans of Saunders Law and Rachel Barrett of Cloisters.

Interested Persons (‘IPs’): deceased’s family, Nottinghamshire Healthcare NHS Foundation Trust (‘NHCT’), East Midlands Ambulance Service NHS Trust (‘EMAS’), and the Care Quality Commission (‘CQC’)

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests