Alice Dearden: Prevention of future deaths report (1)
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Date of report: 29/04/26
Ref: 2026-0231
Deceased name: Alice Dearden
Coroners name: Nicholas Rheinberg
Coroners Area: Wiltshire and Swindon
This report is being sent to: Ebay
 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
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| THIS REPORT IS BEING SENT TO: eBay, 1 More London Place, London, SE1 2AF | |
| 1 | CORONER I am Nicholas Rheinberg assistant coroner, for the coroner area of Wiltshire and Swindon |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 3 | INVESTIGATION and INQUEST On 12th March 2020 an inquest was opened into into the death of Alice, Sarah, Dearden (Alice) aged 19. The investigation concluded at the end of the inquest on 28th April 2026. The conclusion of the inquest was that Alice died by suicide [REDACTED]. |
| 4 | CIRCUMSTANCES OF THE DEATH Alice suffered from mental health difficulties as a result of anorexia nervosa and emotionally unstable personality disorder. Her conditions resulted in acts of self-harm which included overdoses. Initially Alice’s overdoses involved over the counter medication such as paracetamol but during 2019 she began to buy prescription medication on line. Alice’s internet search history included visiting sites which promoted suicide. [REDACTED] a reportable poison under the Poisons Act 1972, as a certain means of dying by suicide. [REDACTED]. On 11th February 2020 Alice bought [REDACTED] from the company and having consumed a quantity of the substance died at her home in Wiltshire on 28th February 2020. |
| 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows. [REDACTED] is a reportable substance under the Poisons Act 1972. A supplier of the substance has a statutory duty to report any suspicious transaction. The statute goes on to give guidance so as to determine what might be a suspicious transaction. Section 3C (4) reads “In deciding whether there are reasonable grounds for suspecting such a thing, regard must be had to all the circumstances of the case, including in particular where the prospective customer (a)appears unclear about the intended use of the substance, (b)appears unfamiliar with the intended use of the substance or cannot explain it plausibly, (c)intends to buy substances in quantities, combinations or concentrations uncommon for private use, (d)is unwilling to provide proof of identity or place of residence, or (e)insists on using unusual methods of payment, including large amounts of cash.” Evidence at the inquest suggested that it would not be possible for a mail order business to make such checks. Reference during the inquest was made to eBay’s Hazardous Materials Policy and it was seen that Reportable Poisons in concentrated form were not included in the list of prohibited items. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 25th June 2026. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Alice’s family, South Wilts Grammar School, Avon & Wiltshire Mental Health Partnership NHS Trust, Wiltshire Council, Oxford Health NHS Foundation Trust and Red Jackets. I have also sent a copy to [REDACTED] the former managing director of [REDACTED] I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. |
| 9 | Dated this 29th day of April 2026 NICHOLAS RHEINBERG |