29 Apr 2026 Alice, Sarah, Dearden (Alice) · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 1
Failure to remove suicide-related content from a website View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Alice, Sarah, Dearden (Alice) · 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
Alice had mental health difficulties, including anorexia nervosa and emotionally unstable personality disorder, and a history of self-harm and overdoses. She bought prescription medication online on 11 February 2020, consumed some of the substance at home in Wiltshire, and died on 28 February 2020. Concern was expressed that website content referring to a method of self-destruction, suicide websites and a link encouraging suicide might assist people inclined towards deliberate self-harm.
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 remove suicide-related content from a website
Wider context from the report “Evidence received at the above inquest included reference to your former company’s website which was seen to still exist. The website includes the detail shown in italics below:
PLEASE NOTE: We do NOT sell the concentrated food preservative used in meat curing under any circumstances. We immediately (same day) stopped selling this back in April 2020 when we discovered it's misuse and the ████████ name being used -
with neither our knowledge nor permission - on a number of dreadful suicide forums
We subsequently then worked with and assisted the Home Office Protect team in helping identify many of the other sellers still on eBay, Etsy and Amazon etc. in requesting that they remove their similar listings because of this misuse.
2025 Update: Thankfully, it is now much more difficult for a member of the public to source this substance. However sadly, and despite the work of the NYT and the BBC in exposing it, the websites are still operating and thriving, currently using a .net domain. It has stated that it will not be complying with the new 2025 UK Online Safety law.
If you are suffering with your mental health and considering suicide, please do contact the Samaritans 24/7 or call 116 123 if in UK. Worldwide list of suicide help charities is HERE (Wikipedia)
There is mention in the above posting, albeit obliquely, to a method of self-destruction, reference to suicide websites and a link to a website encouraging suicide. Concern was expressed at the inquest that were the words in italics not removed individuals of a disturbed disposition, inclined towards deliberate self-harm, might be assisted in their endeavours harm themselves.
” Source location Alice, Sarah, Dearden (Alice) · Prevention of Future Deaths report
Open source report
9 Oct 2025 Leo Alexander Barber · Prevention of Future Deaths report South London
View report summary
Concerns raised 1
Accessibility of potentially harmful online material to vulnerable individuals in mental health crisis View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Google UK Limited
Maintain Search content policies prohibiting content that could directly facilitate serious and immediate harm.
View source
Google UK Limited
Provide suicide and self-harm support information through hotline OneBoxes.
View source
Google UK Limited
Apply specialised ranking approaches to suicide and self-harm queries.
View source
Google UK Limited
Lock SafeSearch and apply a UK-specific filter for known children to remove harmful content from results.
View source
Google UK Limited
Comply with Online Safety Act obligations through risk assessment, Search moderation and related safety measures.
View source See 2 more actions
×
AI-generated summary
Leo Alexander Barber · 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
Leo Alexander Barber, aged 16, died by suicide on 28 November 2023 after stepping in front of a train. The report states that exposure to an online forum discussing methods of suicide probably reinforced his decision to end his life. Concerns include vulnerable people, including children, accessing potentially harmful online material and difficulties obtaining online activity data from service providers outside the jurisdiction of England and Wales.
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 Accessibility of potentially harmful online material to vulnerable individuals in mental health crisis
Wider context from the report “(1) A 16-year-old child in severe mental health crisis was able to access online material which reinforced his decision to end his life. He registered on the ████████ site using his Gmail address and accessed the material on his Android OS ‘phone. I am concerned that there is a risk of future deaths among those in mental health crisis including children while such material is accessible to vulnerable individuals online .
” Source location Leo Alexander Barber · Prevention of Future Deaths report
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 Search content policies prohibiting content that could directly facilitate serious and immediate harm.
Verbatim wording from the response “In relation to suicide and self-harm content, Google Search takes a combination of approaches, including:” Source location Response from Google
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 Provide suicide and self-harm support information through hotline OneBoxes.
Verbatim wording from the response “In relation to suicide and self-harm content, Google Search takes a combination of approaches, including:” Source location Response from Google
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 Apply specialised ranking approaches to suicide and self-harm queries.
Verbatim wording from the response “In relation to suicide and self-harm content, Google Search takes a combination of approaches, including:” Source location Response from Google
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 Lock SafeSearch and apply a UK-specific filter for known children to remove harmful content from results.
Verbatim wording from the response “In relation to suicide and self-harm content, Google Search takes a combination of approaches, including:” Source location Response from Google
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 Comply with Online Safety Act obligations through risk assessment, Search moderation and related safety measures.
Verbatim wording from the response “In relation to suicide and self-harm content, Google Search takes a combination of approaches, including:” Source location Response from Google
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 The website provider, not Google, determines who may register and access the hosted material.
Verbatim wording from the response “We hope this information is helpful although, for clarity, we note that your Report does not suggest that Mr Barber encountered the Site through search results on Google Search. In addition, while your Report indicates that Mr Barber opened an account on the Site using his Gmail address, it is the provider of the Site alone that determines who can sign up to the Site and access the material it hosts.” Source location Response from Google
Open published response
23 May 2025 William James Armstrong · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2
Public access to websites promoting lethal poisons, administration methods and sourcing information View source Failure of vendors to identify distribution of their website details on suicide-method platforms View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
William James Armstrong · 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
William James Armstrong, aged 24, died after deliberately self-administering a significant quantity of a toxic substance following its internet purchase. He was found unresponsive in a hotel room after an ambulance response delay, and the report states that the consequence of the delay cannot be established. Concerns included gaps in guidance and training for sellers of the substance, the assessment of small-quantity purchases as legitimate use, and public access to websites promoting poisons and suicide methods.
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 Public access to websites promoting lethal poisons, administration methods and sourcing information
Wider context from the report “3. The police investigation revealed the ability of members of the public to access a number of websites , primarily created in the USA, Canada and Mexico that promoted information as to how to access:
a. Poisons that could bring about death
b. How, in what way and with which other necessary preparations (in particular -antiemetic medications) the poisons should be administered.
c. Sourcing such poisons/chemicals/medications in the UK and abroad.
” Source location William James Armstrong · Prevention of Future Deaths report
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 vendors to identify distribution of their website details on suicide-method platforms
Wider context from the report “2. The police investigation into one UK based source of supply revealed in 247 cases separate supplies of 500 grams of less of ████████ to customers in the UK and Europe, police established that 85 of these individuals who were traceable had either died as the consequence of self-ingestion of the substance, or had purchased it with a view to having the means to use this method to end their life in circumstances where:
a. the vendors of the ████████ were not aware of this potential misuse of the substance.
b. the small quantities being purchased had been incorrectly evaluated to be an increase in individuals pursuing recreational home-curing/food preservations as a hobby, being an artefact of ‘lockdown’ living following the COVID national pandemic emergency.
c. Vendors were unaware that their website/details were being distributed as part of internet information platforms designed to aid, abet, assist or promote suicide methods.
” Source location William James Armstrong · Prevention of Future Deaths report
Open source report
23 May 2025 Shaun Michael Bass · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1
Lack of vendor awareness of website distribution through platforms promoting suicide methods View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Shaun Michael Bass · 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
Shaun Michael Bass, aged 23, was found collapsed and unresponsive at his residence on 23 February 2020 after ingesting a fatal quantity of sodium nitrate/nitrite. The report identified concerns about gaps in continuity of mental healthcare, a missed mental health assessment review, inadequate responses to family concerns, and the availability and online promotion of reportable poisons for self-harm.
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 vendor awareness of website distribution through platforms promoting suicide methods
Wider context from the report “2. The police investigation into one UK based source of supply revealed in 247 cases separate supplies of 500 grams of less of ████████ to customers in the UK and Europe, police established that 85 of these individuals who were traceable had either died as the consequence of self-ingestion of the substance, or had purchased it with a view to having the means to use this method to end their life in circumstances where:
a. the vendors of the ████████ were not aware of this potential misuse of the substance.
b. the small quantities being purchased had been incorrectly evaluated to be an increase in individuals pursuing recreational home-curing/food preservations as a hobby, being an artefact of ‘lockdown’ living following the COVID national pandemic emergency.
c. Vendors were unaware that their website/details were being distributed as part of internet information platforms designed to aid, abet, assist or promote suicide methods.
d. From the specific example of 247 supplies in a 12 month period, police established that 45 purchasers were confirmed as deceased (these deaths were in relation to supplies to UK customers and purchasers from abroad) and only 15 purchases were confirmed to have taken place for legitimate purposes (meat curing etc.).
” Source location Shaun Michael Bass · Prevention of Future Deaths report
Open source report
×
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 Online suicide and self-harm forum regulation falls within DSIT’s responsibility under the Online Safety Act, working with Ofcom.
Verbatim wording from the response “Finally, I understand the troubling concerns you have raised about the pro-suicide forums. DSIT, as the department responsible for the Online Safety Act, is committed to working with Ofcom and bereaved families. This partnership aims to ensure the Act protects all users from illegal suicide and self-harm content and shields children from harmful material that does not meet the criminal threshold.” Source location Response from Home Office
Open published response
23 May 2025 Andrew Alexander Roger BROWN · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1
Failure of vendors to identify distribution of their website details on suicide-method platforms View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Andrew Alexander Roger BROWN · 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
Andrew Alexander Roger BROWN was found collapsed and unresponsive at his residence on 9 August 2023 and was pronounced dead after paramedics attended. The cause of death was toxicity from a self-administered poison, although his intentions remained unclear. Concerns included gaps in guidance for online sellers and the public regarding suspicious purchases and the potential use of the poison for suicide or self-harm, as well as access to websites providing information about obtaining and administering poisons.
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 of vendors to identify distribution of their website details on suicide-method platforms
Wider context from the report “2. The police investigation into one UK based source of supply revealed in 247 cases separate supplies of 500 grams of ████████ to customers in the UK and Europe, police established that 85 of these individuals who were traceable had either died as the consequence of self-ingestion of the substance, or had purchased it with a view to having the means to use this method to end their life in circumstances where:
a. the vendors of the ████████ were not aware of this potential misuse of the substance.
b. the small quantities being purchased had been incorrectly evaluated to be an increase in individuals pursuing recreational home-curing/food preservations as a hobby, being an artefact of ‘lockdown’ living following the COVID national pandemic emergency.
c. Vendors were unaware that their website/details were being distributed as part of internet information platforms designed to aid, abet, assist or promote suicide methods.
” Source location Andrew Alexander Roger BROWN · Prevention of Future Deaths report
Open source report
×
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 regulating and enforcing online safety duties covering suicide-related illegal content on in-scope services.
Verbatim wording from the response “The Online Safety Act applies to services even if the companies providing them are overseas, should they have links to the UK. This includes if the service has a significant number of UK users, if the UK is a target market, or if it is capable of being accessed by UK users and there is a material risk of significant harm to such users.” Source location Response from the Home Office
Open published response
23 May 2025 Chantelle Williams · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1
Failure to identify distribution of vendor websites and details on suicide-method platforms View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Chantelle Williams · 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
Chantelle Williams was found collapsed and unresponsive in her room on Keats Ward on 29 May 2020 and could not be resuscitated. Post-mortem analysis identified fatally toxic levels of two substances, likely from a batch she had previously sourced, retained and hidden. The report raises concerns about the online sale and regulation of reportable poisons, the failure to identify suspicious purchases for self-harm or suicide, and websites providing information about obtaining and using poisons to cause death.
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 identify distribution of vendor websites and details on suicide-method platforms
Wider context from the report “2. The police investigation into one UK based source of supply revealed in 247 cases separate supplies of 500 grams or less of ████████ to customers in the UK and Europe, police established that 85 of these individuals who were traceable had either died as the consequence of self-ingestion of the substance, or had purchased it with a view to having the means to use this method to end their life in circumstances where:
a. the vendors of ████████ were not aware of this potential misuse of the substance.
b. the small quantities being purchased had been incorrectly evaluated to be an increase in individuals pursuing recreational home-curing/food preservations as a hobby, being an artefact of ‘lockdown’ living following the COVID national pandemic emergency.
c. Vendors were unaware that their website/details were being distributed as part of internet information platforms designed to aid, abet, assist or promote suicide methods.
” Source location Chantelle Williams · Prevention of Future Deaths report
Open source report
×
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 Online suicide and self-harm forum regulation falls within DSIT’s responsibility under the Online Safety Act, working with Ofcom.
Verbatim wording from the response “Finally, I understand the troubling concerns you have raised about the pro-suicide forums. DSIT, as the department responsible for the Online Safety Act, is committed to working with Ofcom and bereaved families. This partnership aims to ensure the Act protects all users from illegal suicide and self-harm content and shields children from harmful material that does not meet the criminal threshold.” Source location Response from Home Office
Open published response
23 May 2025 Samuel David Dickenson · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2
Failure to detect distribution of vendor website details on suicide-method platforms View source Public access to websites providing suicide-poison access, administration and sourcing information View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Home Office
Engage online platforms to encourage voluntary removal of high-purity sodium nitrite listings.
View source
×
AI-generated summary
Samuel David Dickenson · 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
Samuel David Dickenson died after ingesting a substance acquired over the internet and was confirmed dead in hospital on 11 March 2020. The concerns relate to gaps in guidance and oversight of online sales of reportable poisons, including the failure to identify or address purchases intended for suicide or self-harm, and the availability of online information promoting access to poisons and methods of administration.
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 detect distribution of vendor website details on suicide-method platforms
Wider context from the report “2. The police investigation into one UK based source of supply revealed in 247 cases separate supplies of 500 grams of less of ████████ to customers in the UK and Europe, police established that 85 of these individuals who were traceable had either died as the consequence of self-ingestion of the substance, or had purchased it with a view to having the means to use this method to end their life in circumstances where:
a. the vendors of the ████████ were not aware of this potential misuse of the substance.
b. the small quantities being purchased had been incorrectly evaluated to be an increase in individuals pursuing recreational home-curing/food preservations as a hobby, being an artefact of ‘lockdown’ living following the COVID national pandemic emergency.
c. Vendors were unaware that their website/details were being distributed as part of internet information platforms designed to aid, abet or promote suicide methods.
d. From the specific example of 247 supplies in a 12 month period, police established that 45 purchasers were confirmed as deceased (these deaths were in relation to supplies to UK customers and purchasers from abroad) and only 15 purchases were confirmed to have taken place for legitimate purposes (meat curing etc.).
” Source location Samuel David Dickenson · Prevention of Future Deaths report
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 Public access to websites providing suicide-poison access, administration and sourcing information
Wider context from the report “3. The police investigation revealed the ability of members of the public to access a number of websites, primarily created in the USA, Canada and Mexico that promoted information as to how to access:
a. Poisons that could bring about death
b. How, in what way and with what other necessary preparations (in particular -antiemetic medications) the poisons should be administered.
c. Sourcing such poisons/chemicals/medications in the UK and abroad.
” Source location Samuel David Dickenson · Prevention of Future Deaths report
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 Engage online platforms to encourage voluntary removal of high-purity sodium nitrite listings.
Verbatim wording from the response “While sodium nitrite remains widely used for legitimate purposes (e.g., food curing, industrial applications), retailers in Great Britain are legally obliged to report suspicious transactions under the Poisons Act 1972. Border Force officers have been issued guidance on identifying and intercepting consignments suspected for self-harm use. The Home Office also engages with online platforms to encourage voluntary removal of listings for high purity sodium nitrite.” Source location Response from Home Office
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 Online suicide and self-harm forum regulation falls within DSIT’s responsibility under the Online Safety Act, working with Ofcom.
Verbatim wording from the response “Finally, I understand the troubling concerns you have raised about the pro-suicide forums. DSIT, as the department responsible for the Online Safety Act, is committed to working with Ofcom and bereaved families. This partnership aims to ensure the Act protects all users from illegal suicide and self-harm content and shields children from harmful material that does not meet the criminal threshold.” Source location Response from Home Office
Open published response
23 May 2025 Mathew Anthony Price · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2
Public access to websites promoting information on obtaining and administering poisons for suicide View source Failure of vendors to know when their website details are distributed to promote suicide methods View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Home Office
Engage online platforms to encourage voluntary removal of high-purity sodium nitrite listings.
View source
×
AI-generated summary
Mathew Anthony Price · 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 28 June 2021, Mathew Anthony Price was found collapsed and unresponsive at his residence after consuming a significant and fatally toxic quantity of a substance. The report identifies concerns about the sale and purchase of the substance, including inadequate guidance for sellers and the failure to recognise small-quantity purchases as potential self-harm risks. It also describes online access to information about poisons and methods of suicide.
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 Public access to websites promoting information on obtaining and administering poisons for suicide
Wider context from the report “3. The police investigation revealed the ability of members of the public to access a number of websites , primarily created in the USA, Canada and Mexico that promoted information as to how to access:
a. Poisons that could bring about death
b. How, in what way and with other necessary preparations (in particular -antiemetic medications) the poisons should be administered.
c. Sourcing such poisons/chemicals/medications in the UK and abroad.
” Source location Mathew Anthony Price · Prevention of Future Deaths report
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 vendors to know when their website details are distributed to promote suicide methods
Wider context from the report “2. The police investigation into one UK based source of supply revealed in 247 cases separate supplies of 500 grams of less of ████████ to customers in the UK and Europe, police established that 85 of these individuals who were traceable had either died as the consequence of self-ingestion of this substance, or had purchased it with a view to having the means to use this method to end their life in circumstances where:
a. the vendors of the ████████ were not aware of this potential misuse of the substance.
b. the small quantities being purchased had been incorrectly evaluated to be an increase in individuals pursuing recreational home-curing/food preservations as a hobby, being an artefact of ‘lockdown’ living following the COVID national pandemic emergency.
c. Vendors were unaware that their website/details were being distributed as part of internet information platforms designed to aid, abet, assist or promote suicide methods.
” Source location Mathew Anthony Price · Prevention of Future Deaths report
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 Engage online platforms to encourage voluntary removal of high-purity sodium nitrite listings.
Verbatim wording from the response “While sodium nitrite remains widely used for legitimate purposes (e.g., food curing, industrial applications), retailers in Great Britain are legally obliged to report suspicious transactions under the Poisons Act 1972. Border Force officers have been issued guidance on identifying and intercepting consignments suspected for self-harm use. The Home Office also engages with online platforms to encourage voluntary removal of listings for high purity sodium nitrite.” Source location Response from Home Office
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 Online suicide and self-harm forum regulation falls within DSIT’s responsibility under the Online Safety Act, working with Ofcom.
Verbatim wording from the response “Finally, I understand the troubling concerns you have raised about the pro-suicide forums. DSIT, as the department responsible for the Online Safety Act, is committed to working with Ofcom and bereaved families. This partnership aims to ensure the Act protects all users from illegal suicide and self-harm content and shields children from harmful material that does not meet the criminal threshold.” Source location Response from Home Office
Open published response
23 May 2025 Kelly Michelle Walsh · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1
Failure of vendors to identify distribution of their website details on suicide-method platforms View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Kelly Michelle Walsh · 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
Kelly Michelle Walsh was discovered dead at her residence on 27 February 2021 after ingesting a fatally toxic substance obtained from an internet-based supplier. The report raised concerns about insufficient guidance for online sellers and the failure to identify suspicious small-quantity purchases that may be intended for self-harm. It also identified online access to information about obtaining and using poisons to end life.
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 of vendors to identify distribution of their website details on suicide-method platforms
Wider context from the report “2. The police investigation into one UK based source of supply revealed in 247 cases separate supplies of 500 grams of lest of ████████ to customers in the UK and Europe, police established that 85 of these individuals who were traceable had either died as the consequence of self-ingestion of the substance, or had purchased it with a view to having the means to use this method to end their life in circumstances where:
a. the vendors of the ████████ were not aware of this potential misuse of the substance.
b. the small quantities being purchased had been incorrectly evaluated to be an increase in individuals pursuing recreational home-couring/food preservations as a hobby, being an artefact of ‘lockdown’ living following the COVID national pandemic emergency.
c. Vendors were unaware that their website/details were being distributed as part of internet information platforms designed to aid, abet, assist or promote suicide methods.
” Source location Kelly Michelle Walsh · Prevention of Future Deaths report
Open source report
24 Apr 2025 Jacqueline Anne Potter · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 1
Failure to restrict in-patient access to self-harm websites through secure unit Wi-Fi View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
National Institute for Health and Care Excellence Somerset NHS Foundation Trust
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AI-generated summary
Jacqueline Anne Potter · 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
Jacqueline Anne Potter, known as Anne, died on 5 December 2022 after taking a car and deliberately driving into the path of an HGV tanker on the A303 during overnight leave from a psychiatric unit. The report raises concerns about families not receiving a codified risk and safety planning document for a patient’s first overnight leave, unrestricted access to self-harm websites through secure unit Wi-Fi, and inadequate recognition and provision of menopausal care and training.
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 restrict in-patient access to self-harm websites through secure unit Wi-Fi
Wider context from the report “(2) It transpired during the Inquest that if an in-patient (detained or voluntary) accesses the secure unit Wi-Fi there are no algorithms or ‘search detection features’ to prevent access to websites pertaining to self harm and so these can be readily accessed by a group who are already vulnerable due to their acute mental health presentation with some element of inherent risk of suicide . It was noted, quite rightly, by legal representatives that workplace organisations can block access to certain sites they deem it undesirable for their workforce to access (such as sites relating to gambling, sexually inappropriate content etc) which shows that it is possible to limit access to certain websites and content when using a Wi-Fi provider. By allowing an already vulnerable group to have unfettered access to websites dedicated to self harm creates a risk of further deaths .
” Source location Jacqueline Anne Potter · Prevention of Future Deaths report
Open source report
×
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 Mobile-device filtering cannot currently be added because the available blocking programme is not suitable for mobile devices.
Verbatim wording from the response “Additionally, some desktop devices in some inpatient mental health sites have a browser extension loaded onto the device which can divert users away from certain search terms to a free, 24/7 mental health support site. This can only be used on PCs and is not suitable for mobile devices, but it effectively blocks patients accessing this type of information when they see a search engine on a ward PC e.g. google, safari. Our IT team explained that they could not currently see that this programme is available to download onto mobile devices.” Source location Response from Somerset NHS Foundation Trust
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 Changes to public NHS Wi-Fi require county-wide implementation and would affect all devices connected to that network.
Verbatim wording from the response “Private devices would not connect to the Trust Network, due to security reasons, and instead would connect to the public ‘NHS Wi-Fi’ which is essentially a connection straight out to the internet. Any changes made to this connection would have to be made county-wide and would affect all devices which connect to it.” Source location Response from Somerset NHS Foundation Trust
Open published response
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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 Managing Wi-Fi access to harmful websites in NHS facilities is outside NICE’s responsibility, so NICE cannot comment.
Verbatim wording from the response “2. Wi-Fi access to harmful websites whilst in NHS facilities.” Source location Response from NICE
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.