Jonathan Shaw: Prevention of future deaths report

Suicide (from 2015)

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Date of report: 25/04/2024

Ref: 2024-0223

Deceased name: Jonathan Shaw

Coroner name: Catherine McKenna

Coroner Area: Manchester North

Category: Suicide (from 2015)

This report is being sent to: National Police Chiefs Council | Home Office

[REDACTED], Chair of the National Police Chiefs Council
The Rt Hon James Cleverly MP, Secretary of State for the Home Office (Border Force)
I am Catherine McKenna, Area Coroner for the Coroner Area of Manchester North
I make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013
On 6 December 2023 an investigation into the death of Dr Jonathan Harvey Shaw was commenced. The investigation concluded at the end of the inquest on 24 April 2024. I recorded a conclusion of Suicide. The medical cause of death was 1a) fatal nitrite/nitrate toxicity.
Dr Jonathan Shaw took his own life through the intentional ingestion [REDACTED] which he had procured through an online purchase from a company that operates in Malaysia. Before the package [REDACTED] was delivered to Dr Shaw, it had been stopped by UK Border Force at the request of the National Fast Parcel Targeting Team who received intelligence about the Malaysian company and information about concerns for Dr Shaw’s welfare and the risk to life. Officers from Greater Manchester Police (GMP) made contact with Dr Shaw and informed him that the parcel had been stopped by UK Border Force. There is no evidence that the officers were informed by UK Border Force of the timescales before release and the officers would most likely not have been aware that UK Border Force could only lawfully keep hold of the package for 30 days. UK Border Force released the package 9 days after its arrival in the UK and without examining its contents or consulting with GMP. The lack of consultation with GMP represented a significant missed opportunity as the evidence was that Dr Shaw would most likely have agreed to the safe destruction of the package if he had been asked at a point before he took physical possession of it. In the event, Dr Shaw concealed the package and informed his family, the police and mental health professionals that he had disposed of it. He subsequently used the contents of the package to end his life.
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows:- The UK Border Force do not have the legal powers to seize a consignment of [REDACTED] because it is not a prohibited poison under the Poisons Act 1972. If there is an ongoing police investigation or police interest in a particular consignment, the UK Border Force can use section 19 of the Police and Criminal Evidence Act 1984 to stop and hold.  However the holding power is limited to 30 days, after which the consignment must be released. There is no national guidance or training provided to Police Forces or the UK Border Force on joint working around the management of consignments of [REDACTED] from overseas which have been ordered by individuals inside the UK for the purpose of ending their own life. There is no legal requirement to alert the local police force before a consignment is released or to request a welfare check during which the recipient could be invited to agree to the safe destruction of the parcel by the police or UK Border Force.
In my opinion action should be taken to prevent future deaths and I believe each of you respectively have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely 21 June 2024 I, the Area 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.
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:-
The family of Dr Shaw
I have also sent a copy of my report to the following organisations who may find its contents of interest:-
Greater Manchester Police
National Suicide Prevention Strategy Advisory Group
I am also 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 from. 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 by the Chief Coroner.
925 April 2024