Andrew Kenward: Prevention of Future Deaths Report
Alcohol, drug and medication related deathsSuicide (from 2015)
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Date of report: 09/07/2025
Ref: 2025-0346
Deceased name: Andrew Kenward
Coroners name: Anna Loxton
Coroners Area: Surrey
Category: Alcohol, drug and medication related deaths | Suicide (from 2015)
This report is being sent to: Home Office | Department of Health and Social Care
| A Regulation 28 Report – Action to Prevent Future Deaths | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1. [REDACTED], Home Secretary 2. [REDACTED], Secretary of State for Health and Social Care | |
| 1 |   CORONER Ms Anna Loxton, HM Assistant Coroner for Surrey |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. |
| 3 | INVESTIGATION and INQUEST Andrew Nathan Paul Kenward died on 24th October 2022, aged 30. His inquest was opened on 2nd May 2023. A summary inquest took place on 17th June 2025. I recorded a conclusion of Suicide. I found the medical cause of death to be: 1a. [REDACTED] Toxicity |
| 4 | CIRCUMSTANCES OF THE DEATH Early on the morning of 24th October 2022, Andrew Kenward was found deceased in his car parked on a road in Sunbury on Thames, Surrey, from an overdose of a poisonous substance, namely [REDACTED]. Mr Kenward had previously expressed an intention to end his life to a friend and an undated note was found in his bedroom drawer expressing his regret and love for his Family, but that he felt unable to continue living. Two packets of [REDACTED] were also found in Mr Kenward’s bedroom, both stated to contain 50g [REDACTED]. One of these was sealed and weighed 51.45g. The second was resealable and weighed 49.48g. The states purity was “99.999% pure”. The source of these packets remains under Police investigation. |
| 5 | CORONER’S CONCERNS A lethal dose of [REDACTED] can be as small as 1g. Mr Kenward was able to procure a total of 1kg of sodium nitrite at 99.999% purity. Coroners including myself have previously raised in Prevention of Future Death reports that there is no central monitoring system which is able to record incidents of sodium nitrite poisoning, although the use of sodium nitrite for self-harm is increasing. [REDACTED] and [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. Whilst the source of this particular [REDACTED] is not currently known, there are no restrictions on the import of [REDACTED] or [REDACTED] from abroad. Whilst these substances have legitimate uses, including meat preservation, there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose. The MATTERS OF CONCERN are: [REDACTED] can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions; [REDACTED] can be purchased from abroad and imported to Great Britain with no restrictions; [REDACTED] is sold at levels of purity (99%) and in quantities which represent significant risk to life (up to 1000 fatal doses for 1kg sale), whether by self-harm or terrorist use; The quantities and purity in which [REDACTED] are sold do not appear to be those required for their legitimate use, for example in meat preservation; It does not appear there is any consideration of regulating/monitoring the use of [REDACTED] outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this. Consideration should be given as to whether any steps can be taken to address the above concerns. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph one above have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. |
| 8 | COPIES I have sent a copy of this report to the following: 1. See names in paragraph 1 above 2. [REDACTED] 3. The Chief Coroner In addition to this report, I am under a duty to send the Chief Coroner a copy of your response. 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 at the time of your response, about the release or the publication of your response by the Chief Coroner. |
| 9 | Signed: ANNA LOXTON DATED this 9th day of July 2025 |