Source · Prevention of Future Deaths

Oliver Gorman

Ref: 2025-0558 Date: 4 Nov 2025 Coroner: Andrew Bridgman Area: Manchester South Responses identified: 4 / 4

There are inadequate age restrictions on dangerous aerosol products and unclear warnings about instant death. Social media platforms also fail to take responsibility for harmful content promoting such misuse.

Date 4 Nov 2025

56-day deadline 30 Dec 2025 est.

Responses identified 4 of 4

Child Death (from 2015) Wales prevention of future deaths reports (2019 onwards)

Coroner's concerns

AI summary

View full coroner's concerns

1. No Age Restriction The age restriction on the purchase of butane for refilling cigarette lighters (and the like) is 18 years of age. I understand the legislation is primarily aimed at preventing the misuse of butane. The age restriction on the purchase of aerosol paints is 16 years of age. I understand that the legislation is aimed at reducing incidents of graffiti and preventing the misuse of butane/propane - as above. There is no age restriction on the purchase of aerosol or other products containing butane/propane as the propellant, yet their misuse is as equally dangerous. An age restriction on such products would also likely heighten parental awareness of the dangers of such products.
2. Adequacy of Warning The warnings on the cans of of the danger/risk of inhaling the aerosol spray were, in my opinion, inadequate in terms of visibility and wording. The warning was set in an area outline of about 12mm x 12mm, in black or white writing depending on the background colour of the can. It was lost amongst all the other information and writing on the can. At least the ‘inflammable content’ warning was outlined in red. The warning stated “SOLVENT ABUSE CAN KILL INSTANTLY”. Many people (both adults and children) may not equate inhalation of aerosol spray with solvent abuse. Thus, the warning does not appear to properly describe the risks of using/misusing using the product. That risk being inhalation of this aerosol spray can cause instant death.
3. Social media content and access The posting of challenges such as those listed above, and no doubt others, on social media platforms will continue to take the lives of young, impressionable and/or vulnerable children/teenagers unless the platform providers take responsibility fortheir content and/or toxic algorithms either voluntarily or through Government action. The former seems unlikely. Further the age restriction of 13 years formost social media platforms appears to have been determined in relation to data protection laws rather than of the nature of the content to which they will be exposed, again via any toxic algorithms or any searches they may make.

Responses

4 respondents

Product Safety Standards Other

17 Dec 2025 PDF

Action Planned

OPSS highlights industry led labelling initiatives to address risks. Officials will communicate the new industry labelling initiative to relevant groups to raise awareness. (AI summary)

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Dear Mr Bridgman, Thank you for your Regulation 28 Report (Prevention of Future Deaths) dated 4 November 2025, prepared following your investigation and inquest into the death of Oliver Luke Gorman. Your report states Mr Gorman died on 5 May 2025 following inhalation of butane gas from an aerosol deodorant. I am responding on behalf of the Department for Business and Trade in my role as Chief Executive of the Office for Product Safety and Standards (OPSS), which is part of the Department. OPSS is the UK’s national product regulator, responsible for the regulation of most consumer goods except food, vehicles, and medical products. May I first say how sorry I was to hear of Oliver's death. If you have the opportunity, please convey my deepest sympathy to his family. I recognise the devastating harms that misuse of these products can cause, and, like you, I am aware of other tragic deaths of young people caused by inhalation of substances in aerosol products. In responding to the matters of concern raised in your report, I would firstly like to explain how aerosol safety is regulated under the Aerosol Dispensers Regulations
2009. These regulations set out requirements for placing aerosols, including deodorants, on the UK market. This includes affixing a compliance mark (UKCA in Great Britain or the reversed epsilon in Northern Ireland) to confirm the product meets the relevant product safety requirements which includes mitigating risks associated with inhalation of the dispenser’s contents. Aerosols must also meet aerosol-specific labelling requirements under the classification, labelling and packaging of chemicals legislation. This includes warnings and precautionary statements, such as ‘keep out of the reach of children,’ where they are relevant to the aerosol product. Where evidence is available to OPSS regarding products that pose a safety risk or do not comply with the law, we and Local Authority Trading Standards have powers to enforce the law and remove products from the market. As a risk-based, evidence- led regulator, the Office for Product Safety and Standards gathers data on product- related harms from a range of sources, including notifications from local authorities and other regulators about safety issues involving consumer products. We have reviewed these notifications to OPSS and found no reports since 2022 of non- A9

The Office for Product Safety and Standards is part of the Department for Business, Energy and Industrial Strategy. We strive to enhance protections for consumers and the environment and drive increased productivity, growth and business confidence.

compliant or unsafe aerosol deodorants. We have also examined available information from the National Child Mortality Database, which gathers reviews of all child deaths in England. In your report, you raise three matters of concern. I address those within the remit of OPSS below:
1. Age restrictions Your report expressed a concern about the absence of an age limit on the sale of aerosol deodorants (unlike aerosol paints and butane for cigarette lighters). To address the dangers from products that might be abused, the Psychoactive Substances Act 2016 makes it an offence to supply a product containing a psychoactive substance to a person whilst knowing or being reckless about whether it is likely to be consumed for its psychoactive effect. Guidance published by government and trade associations, such as the Association of Convenience Stores, supports retailers to fulfil these responsibilities, and retailers should make sure they are aware of the potential uses of such products so they can effectively exercise their responsibilities in law. Local Authority Trading Standards also support retailers to prevent misuse and protect children, through advice to retailers on refusing sales when misuse is suspected, conducting voluntary age checks and spotting red flags, such as unusual or repeated purchasing patterns. You suggested an age limit on the purchase of aerosol products would help raise awareness among parents and caregivers about the potential associated risks. Aerosol products are common in households, with over 485 million sold in the UK in 2024, according to the British Aerosol Manufacturers Association (BAMA) via Kantar Worldpanel data. Many of these, such as deodorants and hair sprays, are frequently purchased by parents for people under 18, and are typically accessible around the home. While I share your concern at the circumstances of Oliver’s tragic death, it is not clear the available evidence proves that placing an age limit on the purchase of aerosol deodorants would be more effective than the measures currently in place under the existing regulations, or the additional steps the industry is taking on warnings, which I have set out below.
2. Adequacy of warnings You also raised concerns regarding the effectiveness of the warnings on aerosol deodorants currently required by the existing regulations. Awareness raising of potential harms which can be caused by products is vital, particularly for vulnerable groups. Your report suggests that the current warning - Solvent Abuse Can Kill Instantly (known as the ‘SACKI’ label) - does not adequately convey the possible risk of death from inhalation in clear and accessible language or appearance. The SACKI label was introduced in 1997 in response to concerns about awareness of harms caused A10

The Office for Product Safety and Standards is part of the Department for Business, Energy and Industrial Strategy. We strive to enhance protections for consumers and the environment and drive increased productivity, growth and business confidence.

by substance abuse, and has been implemented voluntarily by industry since, with currently around 70 percent of aerosols manufacturers in the UK using the warning, according to the BAMA. Since 2024, businesses have been working with the substance abuse charity Re- Solv and with the BAMA to design a new label to better address concerns, like yours, that the inhalation risks from everyday aerosol items need to be more easily understood. The BAMA is recommending that businesses consider using the new message “Intentional misuse can kill instantly. Do not deliberately inhale.” BAMA are also providing guidance to all UK manufacturers regarding the colour and location for the label to help improve visibility, whilst also meeting the other label requirements set out in legislation including the classification, labelling and packaging of chemicals. I understand that one of the UK market leaders in this industry will implement the new messaging from January 2026, meaning a significant proportion of aerosol products in the UK will soon carry the new label. While this will be voluntary, we expect other businesses to follow suit, and OPSS will be encouraging all aerosol manufacturers to take up the new warning. I understand the BAMA will also encourage their membership to make the change as soon as possible. The voluntary uptake of this clearer label, which includes a reference to the risks as you set out in your report, will lead to a renewed focus on safety from businesses in this industry and further increase the protection of people from inhalation risks. OPSS, with the BAMA’s support, will monitor the progress on the voluntary uptake of the new labelling and we will make clear that we expect industry to be following this updated best practice for products where it is most relevant. Consumer awareness campaigns help individuals to understand and engage with product safety issues, enabling them to make informed purchasing decisions to keep themselves, friends, and family safe from harm. There is a history of work to reduce solvent abuse harm built on collaboration between industry and charities like Re- Solv, and OPSS encourages industry-led initiatives to address risks and compliance issues. We also work closely with charities including the Royal Society for the Prevention of Accidents and the Child Accident Prevention Trust to share information and messages about accident prevention and product-related harms to reach vulnerable groups, and the general public. I have asked my officials to make sure that the new industry labelling initiative is communicated to these groups and others, to ensure awareness is raised as widely as possible.
3. Social media access and content In relation to your matters of concern regarding harmful content accessible across social media platforms, I know you have sent your report to the Department for Culture, Media and Sport and Department for Science, Innovation and Technology, which are best placed to respond to these matters. This is clearly a tragic case, with significant implications that we should learn from. I hope that what I have outlined about the existing product safety framework and A11

The Office for Product Safety and Standards is part of the Department for Business, Energy and Industrial Strategy. We strive to enhance protections for consumers and the environment and drive increased productivity, growth and business confidence.

proposed changes to the warnings, intended to protect people, particularly vulnerable groups, from product-related harms, provides some reassurance. OPSS is determined to work with industry on measures to further protect people from potential risks posed by aerosol deodorants. Thank you again for writing to the Department raising your concerns. Yours A12

Department for Science Innovation and Technology Central Government

17 Dec 2025 PDF

Action Taken

The Department highlights the Online Safety Act (OSA) which requires companies to prevent users from encountering illegal content and remove such content swiftly. Ofcom can issue information notices at the coroner's request, requiring services to provide data and Data Preservation Notices to preserve a child's data. (AI summary)

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Dear Mr Bridgman,

Thank you for giving me the opportunity to respond to your Regulation 28 Report to Prevent Future Deaths dated 4 November 2025, regarding the devastating death of Oliver Gorman. Since taking up my role as Secretary of State for the Department of Science, Innovation and Technology, I have been actively reviewing the issues you have raised in your report, and I am grateful to you for bringing them to my attention.

First and foremost, I want to express my deepest condolences to Oliver’s family and friends. Every death is a tragedy, but it is especially harrowing when it involves someone so young, and with their whole life ahead of them. The circumstances of Oliver’s death are profoundly concerning, and I will ensure your report informs the government’s considerations on how we strengthen online safety for everyone - particularly for children. I also want to assure you that I will be working across government with all relevant Secretaries of State to see what more we can do to stop these very tragic incidents happening.

As you will be aware, the Online Safety Act received Royal Assent in October 2023. This landmark legislation lays the foundation for strong protections against illegal content for all users and harmful material, particularly for children. The independent regulator for online safety under the Act is Ofcom.

The illegal content duties have been in force since March. This means that all companies in scope need to take steps to prevent users from encountering illegal content and criminal behaviour on their services and remove such content swiftly when identified (once aware that it has been uploaded).

The Act delivers important protections for children. Since July, the child safety duties have required all regulated user-to-user services and search services in scope of the Act that are likely to be accessed by children to protect them from harmful content. Sadly, Oliver’s death occurred before these duties came into force, but I want to set out how I hope the safeguards now in place will prevent tragedies like this in the future.

Content that is harmful to children can be categorised as either ‘Primary Priority Content’, ‘Priority Content’ or ‘non-designated content’. Your report highlighted evidence from Oliver’s school, detailing a trend of inhaling to experience a ‘buzz’. Your report stated that this trend is widespread on social media and was a ‘challenge’ that you note was disseminated through TikTok. The Act explicitly defines ‘Priority Content’ as including content which encourages a person to ingest, inject, inhale or in any other way self-administer a physically harmful substance or a substance in such a quantity as to be physically harmful. ‘Priority Content’ also includes content defined as content which encourages, promotes or provides instructions for a challenge (or stunt) highly likely to result in serious injury to the person who does it.

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Platforms such as TikTok must protect children from ‘Priority Content’, while search services have a duty to minimise the likelihood that children in age groups encounter harmful content when searching online.

Ofcom recommends that services which are at medium or high risk of Priority Content and allow this type of content on their service should use highly-effective age assurance to determine whether children are on these parts of the service and put in place appropriate access or content controls.

Your report noted concerns about Oliver being bullied. While you evidence that this was not a factor in Oliver’s death, it is worth highlighting that the Act also defines ‘Priority Content’ to include bullying, abusive, or hateful content. Services in-scope of the Act must also take steps to protect children from this type of content online.

We are also applying more robust duties on services in respect of the most harmful types of content (‘primary priority content’), which includes pornography or content that encourages, promotes or provides instructions for suicide, self-harm or eating disorders, and must prevent children from encountering such content by using highly effective age assurance.

Your report references algorithms on social media services. Under the Act, providers must assess how algorithms may amplify children’s exposure to illegal or harmful content and take action to reduce risks, including for ‘priority content’. If a risk assessment identifies that habit-forming or addictive behaviour (resulting from the design of the service) could cause significant harm to children, providers must implement measures to mitigate and manage this risk. The Act also makes clear that harm can arise from how content is disseminated — for example, when an algorithm repeatedly pushes large volumes of content to a child in a short period.

Services likely to be accessed by children must also provide simple, effective reporting tools for harmful content and respond quickly.

In relation to minimum age limits for access to online services - 13 years-old is commonly the age social media services set as a minimum age. 13 is the digital age of consent in the UK – the age at which a child can consent to their data being processed by online services. This age reflects what was considered at the time the digital age of consent legislation passed to be the right balance between enabling young people to participate online and ensuring their data is protected. Any change to this age threshold would require a formal process, including public consultation, to ensure that the views of all relevant stakeholders such as parents, children, industry, and regulators are fully considered before any legislative amendments are made.

The OSA does not require services to set a minimum age limit. However, Ofcom notes that if a service has a minimum age limit set (as most social media services do) and is not using highly-effective age assurance to enforce this, then they should assume younger children are using their service and apply protections accordingly. This should help ensure that younger children also have age-appropriate online experiences.

Your report references that the challenge or practice of recreationally inhaling deodorant spray was known to be shared on TikTok. However, your report also notes that it was not possible to access Oliver’s mobile phone to determine whether he had been viewing content about dangerous stunts or challenges before his death. It would be helpful to understand further what issues you had accessing Oliver’s phone. It is of utmost importance to me that coroners do not face undue barriers when it comes to preserving or accessing social media data in these tragic circumstances, and so if you wanted to provide further details on why you were unable to access his phone, I would be happy to ensure we look into this further.

As you will likely already be aware, there are existing provisions in the OSA to aid coroners with preservation and access of social media data. Under the OSA, Ofcom can issue information notices at the coroner’s request, requiring services to provide data where a coroner feels it is relevant to an investigation. Since September 2025, Ofcom has also had the power to issue Data Preservation Notices, if requested by coroners, which require services to preserve a child’s data so it cannot be deleted or altered during an investigation. I hope that these powers will make a material difference A7

for you and other coroners in being able to access and preserve social media data, where it may have played a part in a child’s death.

If a platform fails to respond to a Notice, Ofcom can take tough enforcement action - including fines of up to 10% of the companies' qualifying worldwide revenue or £18 million, whichever is greater. I expect Ofcom to use all its enforcement powers to hold platforms accountable where they are failing to meet their duties under the OSA, including in these circumstances.

The government’s mission is clear: children must grow up safe, protected, and free from online harms. I will work relentlessly across government, alongside other Secretaries of State, to prevent tragedies like this from ever happening again. The Online Safety Act is a critical tool in achieving that goal. The protections outlined above are now fully in force, and we are already seeing real tangible improvements in how children experience the online world. But let me be absolutely clear—this is only the beginning. These protections are a foundation from which we will build on if required. My department is working closely with Ofcom to track the impact of the Act, and their flexible approach means we can respond quickly to new and emerging risks. If further action is needed, I will not hesitate to strengthen child safety measures. We will do whatever it takes to ensure children are protected online.

British Aerosol Manufacturers Association

18 Dec 2025 PDF

Action Taken

BAMA has developed a new caution mark and statement that can be used to provide additional detail on the potential problems which can arise if the aerosol dispenser is not used in accordance with the manufacturer’s instructions. The caution mark will be placed in the top two-thirds of the back of the pack copy to ensure that it is noticed by the consumer. (AI summary)

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Dear Mr Bridgman

BAMA response to Regulation 28 Report – Re: Oliver Gorman

Established in 1961, the British Aerosol Manufacturers’ Association (BAMA) represents the whole aerosol industry supply chain. From component suppliers and ingredient manufacturers to machinery makers, fillers and marketers of aerosol products. BAMA membership counts over 90 businesses ranging from individual consultancies to multinational corporations.

BAMA and the wider aerosol industry were deeply saddened to learn of Oliver Gorman's tragic death. Our thoughts are with his family and friends at this challenging time.

Safety is a key priority for the aerosol industry. products are used by millions of people every day and are subject to rigorous safety assessments and clear labelling before they are placed on the market. However, when misuse occurs through deliberate inhalation, these products can become harmful. The industry cares deeply about this issue and has worked for many years to reduce incidents.

Deaths directly attributable to the inappropriate inhalation of are rare. BAMA supports and works closely with Re-Solv, a charity set up to help those using gases and solvents. Figures obtained by Re-Solv* from the Office of National Statistics show that there were three such deaths in 2024. In the UK, sales of aerosol dispensers in 2024 exceeded six hundred million units.

BAMA believes that providing information and education on safety is essential and is committed to ensuring that aerosol marketers provide prominent caution marks on pack, which we believe would be more effective than imposing age restrictions on the sale of . Since the late 1990s, BAMA has asked those placing aerosols on the UK market to add a voluntary caution mark alongside the product information, in addition to the legally required text, that reads “Solvent Abuse Can Kill Instantly” (SACKI).

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A Company limited by Guarantee Registered at Cardiff No. 1763228

Earlier this year, following work with Re-Solv, academia, and consumers on the changing use of language, BAMA updated its advice. It proposed an alternative mark that reads: “Intentional misuse can kill instantly. Do not deliberately inhale” along with suggested wording for an additional cautionary statement. There is also a recommendation regarding where this mark should be placed to make it more prominent to users. More details can be found below or on the BAMA website.

Like other household products, aerosols are safe when used according to the manufacturer's instructions. Products are tested to ensure they comply with all relevant regulations and are labelled, as a minimum, in accordance with those regulations. We believe that the labelling of products, as detailed above, is the best way to raise awareness of the potential dangers of misusing an aerosol, including for parents and those caring for young people.

Currently, most aerosols on sale in the UK carry the SACKI mark. BAMA has promoted and will continue to promote the existing and updated caution labels, encouraging all those placing aerosols on the UK market to apply them, even if the aerosol does not have the potential to be misused. We understand that many brand owners and marketers who are currently using the SACKI mark plan to adopt the new caution mark. BAMA is working closely with industry to encourage the speedy uptake of this.

As aerosol dispensers are ubiquitous household products used for a wide variety of applications, from air fresheners and hairsprays to deodorants and insecticides, we believe that by improving on- pack labelling and highlighting the potential risks of misuse, age restrictions are unnecessary in the retail environment. We believe providing information and education at the point of use is better than at the point of sale. However, BAMA has and will continue to work with retailers to ensure they are fully aware of the potential for aerosols to be misused.

We note the coroner's reference to TikTok challenges. BAMA will write to social media companies to raise awareness of this problem and to encourage them to remove dangerous content. BAMA would also like to offer any assistance it can to UK regulators to help them combat the posting of this kind of material.

*www.re-solv.org Founded in 1984, Re-Solv works to reduce the harms caused by volatile substance abuse (‘VSA’ or ‘solvent abuse’) and the misuse of other legal substances across the UK.

Your sincerely Chief Executive

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A Company limited by Guarantee Registered at Cardiff No. 1763228

Inhalation Caution Mark Since the SACKI mark was introduced in 1997, discussions with academia, a Re-Solv report on Language and Stigma, and consumer research conducted in the cosmetic and toiletries sector have all indicated that, in the UK, the way language is used has changed. To reﬂect these changes, BAMA has developed a new caution mark and statement that can be used to provide additional detail on the potential problems which can arise if the aerosol dispenser is not used in accordance with the manufacturer’s instructions.

Intentional misuse can kill instantly Do not deliberately inhale

Caution Statement Caution: Use only as directed. Do not spray directly into the mouth or nose. Do not deliberately, directly inhale, as this misuse can be harmful or fatal for all ages. Use in short bursts in well- ventilated places. Avoid prolonged spraying. Other product-speciﬁc user instructions may be included. Location and Colour of the Caution Location - It is recommended that the caution mark be placed in the top two-thirds of the back of the pack copy to ensure that it is noticed by the consumer. Colour - The background to the text of the caution mark should be white, or in a contrasting colour to the primary pack colour, to ensure the warning is as visible as possible. The caution mark should be surrounded by a contrasting border to increase visibility against other pack copy. A red border must not be used, as this may cause confusion with statutory CLP labelling.

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Department for Culture Media and Sport Central Government

6 Jan 2026 PDF

Noted

The Department for Culture, Media and Sport acknowledges the report and confirms that the Department for Science, Innovation and Technology (DSIT) leads on online safety. (AI summary)

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Dear Mr Bridgman,

Thank you for your Regulation 28 Report of 4 November regarding the death of Oliver Luke Gorman. I am responding as the Minister for Advertising, and I would like to pass on my sincere condolences to the family and friends of Oliver for their loss. I would also like to apologise for the delay in our response to you.

I can confirm that the Department for Science, Innovation and Technology (DSIT) leads on online safety. My colleague at the department, Minister , Minister for AI and Online Safety in DSIT, is best placed to respond to you on this tragic incident, and will be writing to you regarding this within the statutory timeframe.

Thank you again for your important contribution to this issue.

Report sections

Investigation and inquest

On 06.05.25 an investigation commenced into the death of Oliver Luke Gorman who died on 05.05.25 in his bedroom at his home. Oliver was 12 years of age, having been born on 08.11.12. The inquest concluded on 23.10.25. The medical cause of death was 1a) Inhalation of butane gas How, when and where At about 17.54hrs on 5 May 2025 Oliver Luke Gorman was found deceased in his bed at home, , having recreationally inhaled spray. Conclusion Misadventure

Circumstances of the death

On the afternoon of 05.05.25 Oliver and his family returned home from a Bank Holiday weekend in Wales. Oliver said he was tired and went up to his bedroom. When his mother called for him just before 6.00pm he didn’t respond. Thinking that Oliver had his headphones on she went up to the bedroom. He was completely unresponsive. Mum called 999 and carried out CPR until paramedics arrived and took over. No cardiac rhythm was ever achieved. Oliver was transferred to Tameside General Hospital where CPR was stopped and death confirmed. An empty can of t fell from Oliver’s bed when his mother pulled the duvet back. Other empty cans were found in the room by Greater Manchester Police on their attendance and scene assessment. Just priorto going away for the weekend Mum had approached Oliver’s school to report some concerns about bullying. Following Oliver’s death, the school and other agencies tried to investigate those concerns but Oliver’s tragic death so affected his friends and fellow pupils making the investigation difficult and nothing substantive was found. In any event, on the evidence if there was an element of bullying in Oliver’s life it did not play a part in his death. 1 heard evidence from Oliver’s school that the recreational craze of spray ( ) to experience the buzz from the propellant's butane and/or propane is widespread on social media, including and particularly Tiktok. The school’s Summer 25 Safeguarding Letter added its list of Harmful Trends and Challenges which already included, It was not possible to access Oliver’s mobile phone to determine whether Oliver had indulged in directly from Tiktok. The evidence was that it was however a challenge or practice known to be disseminated through Tiktok.

Action should be taken

In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action.

Similar PFD reports

Shared signals

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Report details

Reference: 2025-0558
Date of report: 4 November 2025
Coroner: Andrew Bridgman
Coroner area: Manchester South

Responses identified

Responses identified 4 of 4

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 30 Dec 2025 (estimated).

Sent to

British Aerosol Manufacturers Association

Department for Business and Trade

Department for Culture, Media and Sport

Department for Science, Innovation and Technology

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