Recurring concern

Failure to provide accessible suicide-prevention service information to people at risk

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First reported 28 Dec 2016•Latest report 7 Apr 2026

Definition

What this concern includes

Includes failures to provide, communicate, update or make accessible suicide-prevention service information, crisis contact details, coping resources or equivalent help-seeking information to people at risk or their families, including failures involving accessibility or contact arrangements that make the information unusable.

Not included

  • Excludes failures of suicide-risk assessment, observation, treatment or escalation where no deficiency in providing suicide-prevention information or contact access is identified.
  • Excludes generic mental-health service access or waiting-time problems that do not concern information about available suicide-prevention support.
  • Excludes failures limited to collecting family or service contact details when the concern is not making suicide-prevention support information available to people at risk or their families.
  • Excludes general communication, staffing, funding or documentation deficiencies unless they directly impair provision or accessibility of suicide-prevention service information.
Reports
8

Distinct published reports

Individual concerns
10

A report can raise multiple concerns

Date range
2016–2026

First to latest report issue date

Stated actions
23

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

The National Trust For Places Of Historic Interest Or Natural Beauty3
Isle of Wight Council2
Amazon UK Services Ltd.1
British Transport Police1
Department for Digital, Culture, Media and Sport1
Department of Health and Social Care1
Google UK Limited1
Home Office1
Midlands Partnership University NHS Foundation Trust1
National Police Chiefs’ Council1
NHS Humber and North Yorkshire Integrated Care Board1
Ofcom1
Office of the Chief Coroner1
Sussex Partnership NHS Foundation Trust1
Warwickshire County Council1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Warwickshire

    AI-generated summary

    Matilda Rose Davis · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Matilda was found deceased at her home shortly after an urgent safeguarding visit concerning her mental health and the welfare of her children. The inquest identified concerns that suicide prevention training was not mandatory for frontline practitioners, that she was not asked directly about suicidal ideation, and that she was not signposted to crisis support services.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to signpost people with possible suicidal thoughts to crisis support services

    Wider context from the report

    “Evidence heard during the inquest confirmed that suicide prevention training is not mandatory for frontline practitioners and staff within Warwickshire Children’s Services. The social worker and support worker who visited Matilda had not received suicide prevention training, although such training was available within the organisation. In the absence of mandatory suicide prevention training, Matilda was not asked directly about suicidal ideation during the visit, where reference was made to suicidal thoughts within the referral context. It was also noted that she was not signposted to crisis support services at that time. The non-mandatory nature of suicide prevention training may give rise to variability in practice when practitioners are required to explore, record, or respond to indications of possible self harm or suicidal thoughts. ”

    Source location

    Matilda Rose Davis · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Establish a refreshed central suicide prevention intranet resource hub supporting access to guidance, training materials and support pathways.

    Verbatim wording from the response

    “Delivery will be through the updated 2024 e-learning programme, ensuring content is aligned with current best practice in suicide prevention, supported by a single, accessible intranet resource hub which signposts to additional resources and pathways for support (including Dear Life). A refreshed and regularly reviewed suicide prevention intranet page will act as the central resource hub, building on the existing WCC Suicide Prevention page and ensuring consistent access to guidance and training materials, as well as signposting resources.”

    Source location

    Response from Warwickshire County Council
    Page 2 · response
    Published 13 April 2026

    Open published response
  2. West Sussex, Brighton and Hove

    AI-generated summary

    Harry Benjamin SOUTHERN · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Harry Southern had a history of mental illness, previous suicide attempt and traumatic events in the final year of his life. He died after tying a ligature around his neck with the intention of ending his life. The report raised concerns that young people and their families may not receive accessible, reliable information or timely contact with mental health and suicide-prevention services, and that funding reductions could further reduce available support.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide young people and their families with information about available suicide prevention services

    Wider context from the report

    “During the course of the Inquest, evidence was provided of the many services available to young men such as Harry who have attempted suicide including services such as the Haven and numbers they can contact if they are suicidal. However, I am concerned that this information is not in fact provided to people in Harry’s circumstances. Evidence was heard from Harry’s father that indicated that in fact the contact numbers are not answered and do not cater for those with hearing difficulties or other disabilities. Young people in particular are not aware of other services such as Papyrus, a charity that has a round the clock suicide prevention helpline aimed at young people who are suicidal. Younger people with mental health difficulties of course will tend to be more familiar with social media and apps to discuss their problems in addition to just conventional phone numbers. I am also alarmed at the evidence given at the Inquest that cutbacks and funding issues may result in services to those with mental health difficulties being reduced even further. The Health Secretary will be copied into this Report because I am concerned this may well be a national problem. The inability of young people in particular with mental health difficulties (and their families) to contact someone at all times who will be able to speak with them (or being made aware that there are agencies who can speak to them) does give rise to a risk of future deaths and action should be taken by the Trust to resolve this. ”

    Source location

    Harry Benjamin SOUTHERN · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of suicide prevention contact services to accommodate people with hearing difficulties or other disabilities

    Wider context from the report

    “During the course of the Inquest, evidence was provided of the many services available to young men such as Harry who have attempted suicide including services such as the Haven and numbers they can contact if they are suicidal. However, I am concerned that this information is not in fact provided to people in Harry’s circumstances. Evidence was heard from Harry’s father that indicated that in fact the contact numbers are not answered and do not cater for those with hearing difficulties or other disabilities. Young people in particular are not aware of other services such as Papyrus, a charity that has a round the clock suicide prevention helpline aimed at young people who are suicidal. Younger people with mental health difficulties of course will tend to be more familiar with social media and apps to discuss their problems in addition to just conventional phone numbers. I am also alarmed at the evidence given at the Inquest that cutbacks and funding issues may result in services to those with mental health difficulties being reduced even further. The Health Secretary will be copied into this Report because I am concerned this may well be a national problem. The inability of young people in particular with mental health difficulties (and their families) to contact someone at all times who will be able to speak with them (or being made aware that there are agencies who can speak to them) does give rise to a risk of future deaths and action should be taken by the Trust to resolve this. ”

    Source location

    Harry Benjamin SOUTHERN · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of suicide prevention contact numbers to provide continuous access to someone able to speak with callers

    Wider context from the report

    “During the course of the Inquest, evidence was provided of the many services available to young men such as Harry who have attempted suicide including services such as the Haven and numbers they can contact if they are suicidal. However, I am concerned that this information is not in fact provided to people in Harry’s circumstances. Evidence was heard from Harry’s father that indicated that in fact the contact numbers are not answered and do not cater for those with hearing difficulties or other disabilities. Young people in particular are not aware of other services such as Papyrus, a charity that has a round the clock suicide prevention helpline aimed at young people who are suicidal. Younger people with mental health difficulties of course will tend to be more familiar with social media and apps to discuss their problems in addition to just conventional phone numbers. I am also alarmed at the evidence given at the Inquest that cutbacks and funding issues may result in services to those with mental health difficulties being reduced even further. The Health Secretary will be copied into this Report because I am concerned this may well be a national problem. The inability of young people in particular with mental health difficulties (and their families) to contact someone at all times who will be able to speak with them (or being made aware that there are agencies who can speak to them) does give rise to a risk of future deaths and action should be taken by the Trust to resolve this. ”

    Source location

    Harry Benjamin SOUTHERN · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Launch multi-agency Neighbourhood Mental Health teams to coordinate access to NHS and voluntary-sector support.

    Verbatim wording from the response

    “In relation to alternative support, I am pleased to say that the Trust has now launched the New Neighbourhood Mental Health teams that you also heard about during the Inquest. As they are multi-agency teams they enable improved access to the breadth of services, be that NHS or voluntary sector services, to provide the best and most accessible support for those experiencing mental ill-health. I know that the importance of working collaboratively was heard throughout Harry's Inquest as he was also receiving support from his GP, a private counsellor and had third sector input too. The new Neighbourhood teams support a co-ordinated approach to ensure all system agency partners are aware of exactly what is available across, what is recognised as being a complex mix of primary and secondary healthcare as well as vital voluntary sectors.”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 2 · response
    Published 20 January 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop and launch consistent online mental-health signposting information, categorised by how people may be feeling.

    Verbatim wording from the response

    “I absolutely recognise, as you say, that not everyone wants or is able to use, telephone contact and the Trust has been pro-actively working with system partners to develop new and consistent online mental health signposting information to make it easier for people to find help. The new online information, which categorises services based on how a person may be feeling, was launched in July 2024 and is promoted by a wide range of NHS, primary care, local authority and voluntary sector partners. Details can be found on the Trust's public website here: Getting help with your mental health :: Sussex Partnership NHS Foundation Trust”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 2 · response
    Published 20 January 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Promote online mental-health signposting information through NHS, primary-care, local-authority and voluntary-sector partners.

    Verbatim wording from the response

    “I absolutely recognise, as you say, that not everyone wants or is able to use, telephone contact and the Trust has been pro-actively working with system partners to develop new and consistent online mental health signposting information to make it easier for people to find help. The new online information, which categorises services based on how a person may be feeling, was launched in July 2024 and is promoted by a wide range of NHS, primary care, local authority and voluntary sector partners. Details can be found on the Trust's public website here: Getting help with your mental health :: Sussex Partnership NHS Foundation Trust”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 2 · response
    Published 20 January 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Promote the 24/7 Text SUSSEX to 85258 mental-health support service through the Trust and partner organisations.

    Verbatim wording from the response

    “An additional service which is now regularly promoted by both the Trust and partner organisations, including campaigns which are targeted specifically at students, is 'Text SUSSEX to 85258'. It is a digital means for people to access help with their mental health. The service, which is delivered through the national text messaging service Shout, is free and is available 24 hours a day, seven days a week.”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 2 · response
    Published 20 January 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Transform Staying Well into an open-access out-of-hours crisis service, rebrand and promote it, and increase its availability.

    Verbatim wording from the response

    “Over the last 18 months, the Staying Well service, which you heard some detail about during Harry's Inquest, has also been transformed into an open access service to provide support to people who are experiencing a self-defined mental health crisis, as an alternative to attending A&E. It is an out-of-hours crisis support service which is co-delivered by voluntary, community and social enterprise (VCSE) providers and the Trust has worked with those VCSE partners to rebrand and promote Staying Well, and increase the hours it is available, resulting in a substantial increase in the number of people attending in person.”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 2 · response
    Published 20 January 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Recruit staff to improve Sussex Mental Health Line capacity.

    Verbatim wording from the response

    “By way of assurance, many actions have already been taken and continue to be taken to improve the accessibility of helpline support in Sussex. Following completion of the SMHL review you heard about during the Inquest, immediate actions have focused on recruitment, working patterns and productivity. Additionally, the gap between demand and financial resource has been formally raised with the Trust's commissioners, NHS Sussex, and ongoing improvement of the SMHL is a key objective within the 2025/26 annual plan.”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 2 · response
    Published 20 January 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Change Sussex Mental Health Line working patterns to improve call accessibility.

    Verbatim wording from the response

    “By way of assurance, many actions have already been taken and continue to be taken to improve the accessibility of helpline support in Sussex. Following completion of the SMHL review you heard about during the Inquest, immediate actions have focused on recruitment, working patterns and productivity. Additionally, the gap between demand and financial resource has been formally raised with the Trust's commissioners, NHS Sussex, and ongoing improvement of the SMHL is a key objective within the 2025/26 annual plan.”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 2 · response
    Published 20 January 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Improve Sussex Mental Health Line productivity to address demand and unanswered calls.

    Verbatim wording from the response

    “By way of assurance, many actions have already been taken and continue to be taken to improve the accessibility of helpline support in Sussex. Following completion of the SMHL review you heard about during the Inquest, immediate actions have focused on recruitment, working patterns and productivity. Additionally, the gap between demand and financial resource has been formally raised with the Trust's commissioners, NHS Sussex, and ongoing improvement of the SMHL is a key objective within the 2025/26 annual plan.”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 2 · response
    Published 20 January 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    A range of accessible community and crisis options, rather than improved helplines alone, is considered sufficient to provide local support 24/7.

    Verbatim wording from the response

    “All the aforementioned collaborative, partner working is part of the national strategy to improve community and crisis services to deliver more mental health crisis care in the community, close to people’s homes, through new models of care and support which is key to the long-term sustainability of the NHS. The aim being to improve accessibility of mental health support, not by focusing on improving helplines etc, but by having a range of accessible options which, collectively provide access to local support 24 hours a day, 7 days a week.”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 3 · response
    Published 20 January 2025

    Open published response
  3. Staffordshire and Stoke-on-Trent

    AI-generated summary

    Jamie Peter Norman PILKINGTON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jamie Peter Norman PILKINGTON died after his vehicle left the road, struck a tree and caught fire in the early hours of 12 March 2023. At the time, he was under the care of Mental Health Services and had been expressing suicidal thoughts. Concerns included failures to complete suicide risk assessments and insufficient exploration and management of issues relevant to his suicide risk during mental health assessments.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide suicide-risk coping and service-contact information

    Wider context from the report

    “During a Mental Health triage with the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide. When referred to and assessed by the Integrated Mental health Team on 3rd March 2023 again there was a failure to complete a Risk Assessment as to his risk of suicide. Furthermore, in an appointment on 3rd March 2023 1. Suicidal/self-harm thoughts not explored in detail. 2. There was no exploration of his statement to the effect he was actively researching methods of taking his own life. 3. There was no exploration regarding efficacy/concordance with medication. 4. There was no discussion around distraction techniques, coping mechanisms or information about contact details for other services. 5. There was no discussion regarding his support network, next of kin etc. 6. There was no indication of next steps, timescales or when he could expect to be informed of the onward plan and no definite date when his case would be discussed with the Multi Disciplinary Team. On hearing evidence of the investigation into the Mental Health care which he received, beyond offering further training and support to nursing staff and mental health professionals, no assurance could be given of a system change to ensure that such Risk Assessments were completed or that appropriate and adequate exploration is made of matters which may affect how the risk of suicide is managed. ”

    Source location

    Jamie Peter Norman PILKINGTON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Train staff in suicide awareness, risk formulation and collaborative safety planning across the organisation.

    Verbatim wording from the response

    “MPFT has explored the guidance and what this means for clinicians working with those who may be at risk of suicide. It is recognised that the existing FACE risk assessment is no longer indicated for use in suicide as it is not possible to predict suicide due to the dynamic nature of this. There is building evidence of the effectiveness of safety planning in suicide mitigation, which requires the training and roll out of safety planning skills and tools across the whole organisation. By December 2023 we had trained 1281 staff across the trust in suicide awareness training (e-learning), the safety planning training is face to face and is resource intensive to deliver due to ensuring fidelity against the model therefore numbers for this are lower.”

    Source location

    Response from Midlands Partnership NHS
    Page 2 · response
    Published 26 February 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Explore adding the Safetool safety-planning function to the electronic patient record.

    Verbatim wording from the response

    “We are exploring the addition of the Safetool (safety planning) onto our electronic patient record system to support the electronic completion of this.”

    Source location

    Response from Midlands Partnership NHS
    Page 2 · response
    Published 26 February 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Roll out collaborative safety planning, replacing traditional suicide risk-assessment approaches.

    Verbatim wording from the response

    “MPFT has developed a three-year suicide prevention plan to address the changes in guidance and practice required to move from the traditional risk assessment and management approaches used in suicide to those of collaborative safety planning led by service users. This plan has five key components:”

    Source location

    Response from Midlands Partnership NHS
    Page 3 · response
    Published 26 February 2024

    Open published response
  4. Inner West London

    AI-generated summary

    Chloe Elizabeth MACDERMOTT · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Chloe Elizabeth MACDERMOTT died at home in the early hours of 23 May 2021 after ingesting a substance purchased through Amazon US. The report identifies concerns about online forums encouraging, assisting and counselling suicide, inadequate age restrictions and signposting to help, harmful content not being effectively removed, and the availability and delivery of the product to UK users without effective border or customs controls.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of prominent signposting to organisations providing suicide-prevention help

    Wider context from the report

    “(6) No prominent signposting is in place to organisations from whom help is available to prevent suicide. ”

    Source location

    Chloe Elizabeth MACDERMOTT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Participate in cross-government suicide-prevention work and continue collaborating with the Home Office and Department of Health and Social Care to explore prevention options.

    Verbatim wording from the response

    “Recognising the importance of informed responses, the Steering Group have disseminated briefing materials to all NPCC force and regional suicide prevention leads. In June 2023, ACC ████████ wrote to all Chief Constables, highlighting the need for preparedness in addressing sodium nitrite related challenges. The Steering Group actively participates in cross-government efforts to address this suicide method. Our focus is on reducing access to sodium nitrate and limiting public awareness of its use in suicides, consistent with national strategies. While the Steering Group plays a crucial role in suicide prevention strategy, it is important to note that the quality and extent of crime investigation, including the investigation of the death in question, are matters for individual Chief Constables. As”

    Source location

    Response from British Transport Police
    Page 2 · response
    Published 28 December 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement suicide-related Search information boxes with the Samaritans, linking users to authoritative support and helplines.

    Verbatim wording from the response

    “• As a further measure to support both vulnerable users and the organisations they turn to for help, Google Search has taken proactive steps by working with the Samaritans to implement “OneBoxes” which display prominently in response to suicide-related queries. These information boxes are designed to provide users with quick and easy access to authoritative resources and support for mental health needs, including a 24 hour helpline and links to the Samaritans’ official website. We also note that when users search specifically for the Site, our systems will surface this Samaritans OneBox, with a phone number for national hotlines.”

    Source location

    Response from Google
    Page 2 · response
    Published 28 December 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Enact the Online Safety Act, establishing illegal-content, child-safety and search-service duties covering suicide and self-harm material.

    Verbatim wording from the response

    “First and foremost, I would like to extend my deepest condolences to the family and friends of Chloe. The government recognises that the internet can, in some cases, be used to share and access appalling content with devastating consequences. As you may know, the act received Royal Assent in October last year. This legislation will force companies to take more accountability for the safety of their users. I will address matters (2)-(8) from the report in my response, as per my department's remit and having engaged with the Ministry of Justice on the areas which fall into their remit.”

    Source location

    Response from DSIT
    Page 1 · response
    Published 28 December 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work closely with Ofcom to accelerate implementation of the online safety regulatory framework.

    Verbatim wording from the response

    “Every suicide is a tragedy, and it is essential that the vital protections delivered for users by the act come into force as soon as possible. My department is working closely with Ofcom to ensure that the implementation of the framework is as short as possible and all users, especially vulnerable users, get the online protections they so greatly need and deserve.”

    Source location

    Response from DSIT
    Page 3 · response
    Published 28 December 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing proportionate police, health-professional and cross-government measures are considered an appropriate response to identified suicide risk.

    Verbatim wording from the response

    “ACC ████████ believes that where necessary, proportionate and reasonable steps within the law are being taken to identify imports of Sodium Nitrate and Nitrite and other emerging novel suicide methods and that Police forces and health professionals continue to provide an appropriate response and support to those identified at risk. The NPCC remains committed to working with the Home Office and DHSC, who lead cross-government work on Suicide Prevention, to explore all options to prevent avoidable deaths and hope that reasonable and appropriate reporting is supported and adhered to at all times with supportive and appropriate links to organisations that can, are able and do support those who may find themselves in crisis at any time https://www.samaritans.org/about-samaritans/media-guidelines/”

    Source location

    Response from British Transport Police
    Page 3 · response
    Published 28 December 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Ofcom cannot enforce regulated services’ new duties until required consultations, Codes of Practice, parliamentary approval and other implementation steps are completed.

    Verbatim wording from the response

    “Although the Act is now law, there are numerous procedural steps needed for the new regime to be fully implemented, and these steps need to be completed before services’ legal duties under the regime – and Ofcom’s ability to enforce those duties – come into force. These steps include, for example, the completion of public consultations (the first is currently open for illegal harms); services understanding and managing the risks of harm to their users; and Parliament approving Ofcom’s final Codes of Practices. We explain our plans to implement the regime below.”

    Source location

    Response from Ofcom
    Page 3 · response
    Published 28 December 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Ofcom is responsible for online safety regulation and will recommend measures for search services and relevant online services.

    Verbatim wording from the response

    “Search services will also have targeted duties that focus on mitigating and minimising the risk of users encountering illegal search content, including illegal suicide and self-harm search content. This includes, under section 27(4), a requirement for search services to take or use, where proportionate, measures to be applied to the services' user support measures. The regulator now responsible for online safety, Ofcom, will recommend measures that search services can put in place to achieve these objectives. These could include removing results for sites that are known to host illegal suicide and self-harm content such as the forum you reference in your report, as well as signposting users that search for suicide methods away from this material and towards sources of support, which you highlight as a measure that was non-existent on the site Chloe had accessed.”

    Source location

    Response from DSIT
    Page 2 · response
    Published 28 December 2023

    Open published response
  5. Isle of Wight

    AI-generated summary

    Annette Jane Lewis · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Annette Jane Lewis died after throwing herself from a cliff at Tennyson Down while in acute distress and behaving unusually. The concerns identified were the absence of fencing at the cliff edge and the lack of signs directing people in mental distress to support such as the Samaritans.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of suicide-prevention signage providing the Samaritans telephone number at Tennyson Down

    Wider context from the report

    “1. I heard evidence from ████████ that there are no fences to protect the public from falling over the edge of the cliff at Tennyson Down, and moreover that there are no signs providing those in some sort of mental distress with the number for the Samaritans. Whilst I acknowledge that putting fences around the edge of the cliff would be a massive undertaking by the landowners, it may prevent a future death if those who are in extremes are reminded that there are people out there who are trained to assist them at that time. 2. Having just concluded a similar inquest involving a woman who threw herself from the top of Culver Cliff where I raised similar concerns with both the National Trust and the Director of Public Health who heads up the Suicide Prevention Group on the Isle of Wight, it seems appropriate that if consideration is being given by these organisations to better signage being implemented at the top of Culver Cliff, at the same time, consideration can also be given to making similar improvements at Tennyson Down. ”

    Source location

    Annette Jane Lewis · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct site visits at Culver and Tennyson Downs with the Isle of Wight Suicide Prevention and Intervention team.

    Verbatim wording from the response

    “2. Engagement with the Suicide Prevention & Intervention, Isle of Wight team. A meeting with ████████ from the group has been scheduled for Friday 3rd April 2020 to conduct site visits to both Culver and Tennyson Downs.”

    Source location

    2020-0004-Response-from-the-Isle-of-Wight-National-Trust-Redacted
    Page 2 · response
    Published 8 February 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct a full internal review of suicide-prevention measures after completing the planned stakeholder meetings.

    Verbatim wording from the response

    “6. Conduct a full internal review of our suicide prevention measures. Once all the above meetings are complete, we will conduct a full review of our measures and implement changes where appropriate.”

    Source location

    2020-0004-Response-from-the-Isle-of-Wight-National-Trust-Redacted
    Page 2 · response
    Published 8 February 2020

    Open published response
  6. Isle of Wight

    AI-generated summary

    Joanna Sarah Louise Orpin · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Joanna Sarah Louise Orpin experienced severe, treatment-resistant agitated depression before leaving home on 13 February 2018 and disappearing near Culver Cliff. Her body was found on mudflats at Bosham Quay on 18 February 2018, and the inquest concluded that she killed herself. The substantive concerns included recurring incidents involving people in mental distress at Culver Cliff and the apparent absence of suicide-prevention signs there.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unavailability of suicide prevention signs at Culver Cliff

    Wider context from the report

    “2. I was also informed that whilst there used to be signs at the top of Culver Cliff akin to those which are found at Beachy Head in East Sussex and the Itchen Bridge in Southampton which have wording such as “Suicidal? Despairing? Call Samaritans on [local number]”, these signs appear to no longer be present. (Since the Inquest, I have been provided with the following proof that these signs once existed from ████████: https://www.alamy.com/culver-down-uk-07th-july-2018-a-samaritans-sign-on-the-edge-of-culver-cliff-on-the-isle-of-wight-uk-reads-talk-to-us-if-things-are-getting-to-you-posted-after-a-spate-of-suicides-from-the-same-spot-yachts-can-be-seen-passing-in-the-background-during-the-round-the-island-yacht-race-on-the-hottest-recorded-day-of-the-year-so-far-at-33-degrees-celsius-credit-matthew-blythealmy-live-news-image211378076.html ) 3. During the course of his evidence, Inspector ████████ told the Inquest that he had made recommendations for these signs to be displayed approximately 3 years ago, and he was aware that a Consultant Psychiatrist had made similar recommendations within the last 12 months. Concerns had been ventilated in relation to how many signs would be required and at what intervals. It was the opinion of Inspector ████████ that just a small number of strategically placed signs (perhaps in the car park, and at various intervals along the length of the fence as well as at places where it is easier to cross the protective fence at the kissing gate) would be adequate – in his words, “If they save just one life, then it would be worthwhile.” I agree with his views. 4. I also heard evidence from ████████, a Consultant Psychiatrist at the Isle of Wight NHS Trust that he sits on a Suicide Prevention Group, and they had also tried to get these signs reinstated at the top of Culver Cliff, to no avail. ”

    Source location

    Joanna Sarah Louise Orpin · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Maintain seven Samaritans signs at Culver Down.

    Verbatim wording from the response

    “I can confirm that a number of measures were already in place at Culver Down, including a total of seven Samaritans signs placed within the past few years. A schematic showing the locations of these signs is at Annex A. In addition, ‘dragons teeth’ (wooden bollards to prevent vehicle access) are in place opposite the exits from the car park and there is a ditch to ground vehicles approaching the cliff edge. There is also a barbed wire fence running the”

    Source location

    2019-0457.-Response-from-the-Isle-of-Wight-National-Trust-Redacted
    Page 1 · response
    Published 8 January 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct site visits at Culver and Tennyson Downs with the Isle of Wight Suicide Prevention and Intervention team.

    Verbatim wording from the response

    “2. Engagement with the Suicide Prevention & Intervention, Isle of Wight team. A meeting with ████████ from the group has been scheduled for Friday 3rd April 2020 to conduct site visits to both Culver and Tennyson Downs.”

    Source location

    2019-0457.-Response-from-the-Isle-of-Wight-National-Trust-Redacted
    Page 2 · response
    Published 8 January 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct a full internal review of suicide-prevention measures after the planned meetings.

    Verbatim wording from the response

    “6. Conduct a full internal review of our suicide prevention measures. Once all the above meetings are complete, we will conduct a full review of our measures and implement changes where appropriate.”

    Source location

    2019-0457.-Response-from-the-Isle-of-Wight-National-Trust-Redacted
    Page 2 · response
    Published 8 January 2020

    Open published response
  7. North Yorkshire

    AI-generated summary

    ROBIN ANDREW JAMES MCEWAN · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    On 26 January 2018, Robin Andrew James McEwan was found hanging in the basement of his home after returning from drinks with workmates. He was taken to Harrogate Hospital, where he was considered brain stem dead and died on 2 February 2018 after life support was withdrawn. The concerns included a lack of direct communication between his private therapy service and GP, limited guidance and support during delays in accessing specialist mental health services, and further possible exploration of family support.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of guidance on accessible self-help therapies and online training for lay supporters of people experiencing suicidal crisis

    Wider context from the report

    “Within the contexts of a) Primary Care and b) acknowledgement that referral access to specialist mental health services is considerably delayed and c) recourse to private therapy was sought in the meantime pending any referral and d) there are resources that can be shared in the ‘waiting’ period then: (1) there was a disconnect in communication between that private therapy service and the GP. They were not sharing directly potentially key information that may have influenced concerns and decisions as to Mr McEwan’s welfare and safety; (2) there was evidence of regard to specific mental health approach and self help by the GP but it was stated that there were other approaches and in particular that a significant number of Health Trusts and CCGs reportedly subscribe to one known as “Zero Suicide Alliance”; (3) that there was no other guidance specifically to particular self help therapies that might be free of charge (or covered by the CCG if not), nor to online training package(s) for lay people supporting others experiencing suicidal crisis; (4) there might have been more exploration of potential support by and working with the patient’s family to the intent that mental health ‘scaffolding’ was in place when no other professional help might be immediately available ”

    Source location

    ROBIN ANDREW JAMES MCEWAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review and further develop the CCG website to provide shared mental-health and suicide-prevention information, self-help tools, and support tools for carers and relatives.

    Verbatim wording from the response

    “The CCG, as part of the Mental Health and Learning Disability Strategic Partnership, will be considering how the CCG’s website can be further developed to include a portal to promote initiatives such as the Living Well in North Yorkshire scheme run by North Yorkshire County Council aimed at tackling social isolation. The CCG, as detailed in the attached action plan (appendix one; point 5) will review its website to include shared best practice and innovation, developed both locally and elsewhere, to include initiatives such as Time to Talk and Community Living Well for both patients and GPs.”

    Source location

    2018-0325-Response-by-Harrogate-CCG
    Page 3 · response
    Published 24 February 2019

    Open published response
  8. Cornwall and Isles of Scilly

    AI-generated summary

    SIMON DENNIS CHARLES · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Simon Charles was found dead in the sea at Hells Mouth on 3 July 2016 after a concern for welfare search. He had been suffering from depression and had previously made a serious attempt to take his own life. Concerns were raised about the lack of additional preventive measures at Hells Mouth, including suicide-support signage and natural barriers.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of suicide support agency telephone numbers at Hells Mouth

    Wider context from the report

    “The Family and others at inquest raised concerns that there are not more preventive measures (apart from a fence) to those contemplating suicide (or undertaking risky behaviour) at Hells Mouth, which is a renowned suicide location in Cornwall. They provided examples of the type of measures which they felt could additionally be put in place such as: • Providing the telephone number of suicide support agencies such as the Samaritans in the same way as at Beachy Head, East Sussex • Using natural barriers at the edge of the cliff such as encouraging or planting gorse or other such plants as in Devon along the coast line especially where falls have been known to have occurred The coastline around Cornwall and in particular, the area around Hells Mouth are owned by the National Trust. It would require the consent of the National Trust to put up such signs or other preventative measures and this is the reason for raising the concerns with you and your organisation. ”

    Source location

    SIMON DENNIS CHARLES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Investigate options for installing safety signage at Hells Mouth with Cornwall Samaritans.

    Verbatim wording from the response

    “I can confirm that our local team are in contact with ████████ Director of Cornwall Samaritans, to investigate options for introducing signage at Hells Mouth. The initial thought from our staff is that it would be most practical to have small signs on the barrier near the cliff edge and potentially larger signs in the car park of the café opposite (where Mr Charles’ parked van was found). The latter would require the agreement of the café owners.”

    Source location

    2016-0465-Response-by-National-Trust.pdf
    Page 1 · response
    Published 28 December 2016

    Open published response
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Data last updated 7 September 2026