A doctor took his own life in Oldham using a substance he had bought from Malaysia, which UK Border Force was unable to prevent from being sent to him.
Dr Jonathan Shaw was born in Oldham but lived at Fog Lane in Didsbury, Manchester, with his wife.
According to a Record of Inquest written by coroner Catherine McKenna, Dr Shaw, 55, had a history of mixed anxiety and depressive disorder.
At his parents home in Middlegate, Oldham, on December 2 last year, he committed suicide by ingesting a poison.
A Prevention of Future Deaths report, also written by Ms McKenna, explained how Dr Shaw had purchased the poison online from Malaysia.
Before the package with the poison in it reached Dr Shaw, it was stopped by UK Border Force at Stansted Airport at the request of the National Fast Parcel Targeting Team, who received intelligence about the company and information about concerns for Dr Shaw’s welfare and the risk to life.
Greater Manchester Police (GMP) made contact with Dr Shaw and told him the package had been stopped, however, Border Force released the package without examining it after nine of the 30 days they could lawfully keep hold of it.
When Border Force released the package, they did so without notifying GMP, which Ms McKenna said "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 before he obtained it.
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Dr Shaw then told his family, the police and mental health professionals that he had disposed of the package, however, he used the poison to end his life.
Ms McKenna said she was concerned that Border Force does not have the legal powers to seize a package containing the poison Dr Shaw used to kill himself because it is not a prohibited poison under the Poisons Act 1972.
She also raised concerns that there is no national guidance or training on local police forces and Border Force to work around managing packages of the poison shipped from overseas which have been ordered for people to use to end their lives.
Ms McKenna was also concerned that there is no legal requirement for Border Force to alert the local police force before a package is released or to request a welfare check where the recipient could be invited to agree to the destruction of the parcel.
A spokesperson for the Home Office said: “We are saddened by the death of Dr Shaw and our thoughts are with his friends and family at this difficult time.
“We are considering the findings of the coroner’s report and the Home Secretary will respond in due course.”
Greater Manchester Police declined to comment on the matter.
If you're struggling with your mental health or are in crisis, you can call Samaritans free of charge on 116 123 – they are available 24 hours a day, 365 days a year.
You can also visit www.samaritans.org.
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