Coroner calls for government departments to take ownership of suicide risk from poisonous substance after inquest into the death of 22-year-old Hannah Aitken

Paramedics who treated her were not carrying an antidote to the substance and had not been trained in how to recognise the symptoms of such poisoning.

At the six-day hearing at Surrey Coroner’s Court, HM Assistant Coroner Anna Loxton determined that she would send a Prevention of Future Deaths (PFD) report to the Home Office and the Department of Health highlighting the risks from the ongoing availability of the poison and the need to monitor and assess these risks.

Assistant Coroner Loxton said that ownership needs to be taken of the issue to establish exactly which government department was responsible for addressing the risk of suicide and self-harm from the poisonous substance and that further consideration was required on whether access to the substance should be further limited under the Poisons Act.

At the time of her death, Hannah 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.

Since the age of 12, Hannah had struggled with her mental health and, in 2017, was admitted as an inpatient to a psychiatric hospital. She was subsequently identified as having anorexia nervosa and aged 17, was diagnosed with autism. Hannah spent several years in psychiatric hospitals and supported living accommodation. Over a five-year period, she was admitted to seven different hospitals for mental health treatment at various times.

Hannah was subject to a Community Treatment Order (CTO), which included conditions that she had to engage with mental health professionals and take her medication or be recalled to hospital. Shortly before her death, Hannah had refused to engage with professionals and take her medication, yet she was not recalled to a psychiatric hospital by the agencies involved in her mental health treatment and care at the time.

In their submissions to the inquest, the Aitken family argued that there had been a breach of Hannah’s human rights as a result of the state’s failure to detect and report the risks to life presented by the poisonous substance and by the failure to regulate access to the poison and have in place an effective system to protect life.

During the inquest, the coroner heard evidence from the Home Office, who were designated as an Interested Person in the hearing, about the system of regulation of the poisonous substance.

The coroner heard evidence from the Home Office that the Poisons Act is focused solely on the prevention of terrorism and there is no system of regulation of the poisonous substance to address the risk of suicide and self-harm. The coroner also heard evidence that there is no system of regulation at all in regards to imports of the poison from abroad.

Assistant Coroner Loxton said she couldn’t find that any specific steps 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 and she would be sending a PFD report to the Home Office and Department of Health.

Hannah’s family were represented at the inquest by solicitor Caleb Bawdon with Olivia Fletcher at law firm Leigh Day and barrister Tayyiba Bajwa of Doughty Street Chambers.

Hannah’s father Pete Aitken said:

“As a child, Hannah was bright, kind and active with the most beautiful smile and deep blue eyes. Despite her struggles with her mental health over the years, before she died she was where she wanted to be, living in the community with her beloved dog Milo.

“The evidence from the inquest process has shown to us that Hannah was badly let down by the local mental health team before her death, and that there were shocking shortcomings in the regulation of the poisonous substance she took.

“We have learnt that the risks associated with this poison have been known about for at least five years and that coroner’s have been repeatedly raising concerns about its dangers. Yet clearly, vulnerable adults like Hannah can still get access to it and use it to end their lives.

“We have discovered that there is an antidote to the poison, which tragically was not available to the ambulance crew who treated Hannah. Following a death in the West Midlands the ambulance service there has equipped teams with the antidote as part of a trial which the Coroner was told is now being expanded. We would urge all ambulance services to join this trial.

“Hannah’s inquest also exposed the failings in the care she received from the Surrey and Borders Partnership Trust and the local Tandridge Community Mental Health Team. On numerous occasions we raised our concerns around the care provided by Tandridge CMHRS team and their lack of expertise and experience in caring for Hannah with her complex autistic needs. It is extremely disappointing to us that, having escalated our concerns to the SABP senior leadership, there are no records of any of them having followed up to check that our concerns were being addressed.

“We were grateful to the Coroner for asking the Home Office to attend the inquest and provide evidence on the system of regulation of the poisonous substance. However, to say that we have heard mixed messages from the Home Office is truly an understatement. We were shocked to hear from the Home Office that the objectives of the Poisons Act do not include prevention of suicide and self-harm, and so it was never intended to protect someone like Hannah. We were also very disappointed to hear that the Home Office has no plans to further restrict access to the poison. This is despite knowing of the repeated concerns raised by Coroners about its accessibility, and by their own admission having no knowledge of how widespread legitimate uses of the substance are.

“We feel let down by Surrey Police, who assured us they would be able to access Hannah’s phone, only to tell the Coroner that they were unable to do so. As a result, we are left not knowing how Hannah came to know of the poison and how to obtain it and we are concerned that Surrey Police seemed unable to fully investigate the circumstances of deaths involving this substance.

“We have been defending Hannah’s best interests for the last seven and a half years and have sought to do this diligently through the inquest process with the help of our lawyers. It is very concerning for us that many of the issues raised in the inquest into Hannah’s death have been raised in previous inquests over 5 years, but that the numerous previous Prevention of Future Death reports had not been acted on in time to help Hannah. Our hope is that the Government respond urgently to address the risks this Coroner has again shone a light on, so that fewer families have to go through the pain, trauma and grief we have endured.

“We think the repeated inaction shows the importance of introducing a National Oversight Mechanism. We wholeheartedly support the charity INQUEST’s campaign for an independent, public body to collate, analyse and monitor recommendations and their implementations from post death investigations, inquiries and inquests, and believe it could have made a difference in Hannah’s case.”

Leigh Day solicitor 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. 

“The family have raised major concerns over the regulation and control of the poison that she took and are calling for urgent action to avoid a repeat of such tragedies in future.

“They want to see national ambulance bodies urgently equip their crews with the antidote, and training for paramedics and call handlers to identify poisoning symptoms. They also hope for effective monitoring and data collection of these cases so that the scale of the risk can be understood.

“The Home Office was called to this inquest, against its will, to give evidence which the Aitken family believe revealed the lack of any effective system to regulate this poison to protect from suicide and self-harm. We also heard of the lack of any regulation regarding imports of this substance from abroad, even where the Border Force identify a risk of suicide from a particular package.

“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.”