23 Apr 2026 Thomas Alexander Ferdinand MAYHEW (known as Ned) · Prevention of Future Deaths report East Sussex
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Concerns raised 1 Delays in routing emergency calls concerning apparently deceased persons to ambulance services View source
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Thomas Alexander Ferdinand MAYHEW (known as Ned) · 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 6 May 2024, 16-year-old Ned Mayhew was found hanging in a wooded area after leaving school and was taken to hospital, where his death was confirmed on 9 May 2024 following brain stem testing. The principal concern was that routing an emergency call reporting an apparently deceased person to the police before the ambulance service may result in valuable minutes being lost during the limited period in which treatment might prevent death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Delays in routing emergency calls concerning apparently deceased persons to ambulance services
Wider context from the report “I heard expert evidence from a Consultant Intensive Care Physician, who explained that there is a limited window of time (approximately ten minutes) during which emergency life-saving treatment can be provided to a person who has applied a ligature, such that cerebral hypoxia may be prevented. Cerebral hypoxia, if not reversed, may ultimately lead to cardiac arrest and death. The expert confirmed that if medical intervention is delivered within this critical period, death may be prevented.
The expert further confirmed that a person who has applied a ligature may appear deceased to an observer, for example, displaying no movement and being unconscious, while nevertheless remaining within that ten-minute window during which the outcome may still be altered.
I also heard evidence regarding the Public Emergency Call Service Code of Practice (“PECS”). I was told that where a member of the public contacts emergency services to report the discovery of an apparently deceased person, the call would likely be directed to the police in line with the PECS. In addition, I heard that where a caller is unsure which emergency service they require, the operator must connect the caller to the police, in accordance with a request made by the National Police Chiefs’ Council.
Having considered the expert evidence, I am of the view that in these critical circumstances every second is of importance. The process of routing a caller to the police, who may then refer the matter to the ambulance service and/or instruct an ambulance to attend, carries a risk that valuable minutes may be lost.
” Open source report
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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 Continue working with operational partners to reflect any agreed improvements appropriately in the PECS Code of Practice.
Verbatim wording from the response “Thank you again for bringing this matter to our attention. We hope this response provides assurance that the issues you have identified are being considered with the seriousness they deserve, and that DSIT will continue to work with operational partners to ensure any agreed improvements are reflected appropriately in the PECS Code of Practice.” Source location Response from Department for Science, Innovation and Technology
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage operational partners to consider the proposed change and decide whether to adopt it as standard practice.
Verbatim wording from the response “We coordinate closely with emergency service organisations and BT, as the 999 call handling agent, to ensure that the Code of Practice reflects agreed operational practice and supports the prioritisation of life-saving interventions. Following receipt of your report, we have engaged with the relevant operational partners who can advise on the proposal (BT, ambulance services, and policing, including through the 999 Liaison Committee and consultation with the National Police Chiefs' Council (NPCC)) to consider the issues raised and decide whether the proposed change” Source location Response from Department for Science, Innovation and Technology
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PFD Monitor interpretation Operational delivery of emergency services, including police and ambulance response and control-room decisions, is outside the department’s responsibility.
Verbatim wording from the response “We were very saddened to hear of the case involving Ned, and we wanted to thank you for raising this important matter so that it can be considered by the relevant authorities accordingly. We recognise the seriousness of the issues raised and welcome the opportunity to respond. While we are not responsible for the operational delivery of emergency services, including police and ambulance response or control room decision-making, we maintain the Public Emergency Call Service (PECS) Code of Practice on behalf of the 999/112 Liaison Committee. The Liaison Committee is the primary governing body responsible for the technical and operational oversight of the UK's Public Emergency Call Service.” Source location Response from Department for Science, Innovation and Technology
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation BT and emergency services develop and implement the detailed operational policies and processes for handling emergency calls.
Verbatim wording from the response “The Code of Practice is not a formal policy statement, but provides guidance to organisations on the handling of 999/112 public emergency telephone calls between the Call Handling Agents and the Emergency Authorities in the UK. The detailed operational policies and processes set out within the Code are developed and implemented by BT, as the call handling agent, and the emergency services, drawing on their operational expertise. We work with these partners to bring forward agreed updates to the PECS and ensure that changes are formally reflected and applied consistently across the emergency call system.” Source location Response from Department for Science, Innovation and Technology
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operational partners decide whether the proposed change should be adopted into standard practice.
Verbatim wording from the response “We coordinate closely with emergency service organisations and BT, as the 999 call handling agent, to ensure that the Code of Practice reflects agreed operational practice and supports the prioritisation of life-saving interventions. Following receipt of your report, we have engaged with the relevant operational partners who can advise on the proposal (BT, ambulance services, and policing, including through the 999 Liaison Committee and consultation with the National Police Chiefs' Council (NPCC)) to consider the issues raised and decide whether the proposed change” Source location Response from Department for Science, Innovation and Technology
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4 Nov 2025 Oliver Luke Gorman · Prevention of Future Deaths report Manchester South
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Concerns raised 5 Inadequate visibility and wording of aerosol inhalation warnings View source Failure of social media platforms to control dangerous challenge content View source Lack of age restrictions on aerosol products and other products containing butane/propane propellant View source Failure to control toxic social media algorithms View source Age restrictions for social media platforms failing to account for hazardous content exposure View source See 2 more concerns
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AI-generated summary
Oliver Luke Gorman · Prevention of Future Deaths report
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Report summary
Oliver Luke Gorman, aged 12, died at home on 5 May 2025 after inhaling butane gas from an aerosol spray. The report raised concerns about the lack of age restrictions on some products containing butane or propane, the adequacy of warnings about inhalation risks, and social media content promoting dangerous challenges.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Inadequate visibility and wording of aerosol inhalation warnings
Wider context from the report “2. Adequacy of Warning
The warnings on the cans of ████████ of the danger/risk of inhaling the aerosol spray were, in my opinion, inadequate in terms of visibility and wording.
The warning was set in an area outline of about 12mm x 12mm, in black or white writing depending on the background colour of the can. It was lost amongst all the other information and writing on the can. At least the ‘inflammable content’ warning was outlined in red.
The warning stated “SOLVENT ABUSE CAN KILL INSTANTLY”.
Many people (both adults and children) may not equate inhalation of aerosol spray with solvent abuse. Thus, the warning does not appear to properly describe the risks of using/misusing using the product. That risk being inhalation of this aerosol spray can cause instant death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Failure of social media platforms to control dangerous challenge content
Wider context from the report “3. Social media content and access
The posting of challenges such as those listed above, and no doubt others, on social media platforms will continue to take the lives of young, impressionable and/or vulnerable children/teenagers unless the platform providers take responsibility fortheir content and/or toxic algorithms either voluntarily or through Government action. The former seems unlikely.
Further the age restriction of 13 years for most social media platforms appears to have been determined in relation to data protection laws rather than of the nature of the content to which they will be exposed, again via any toxic algorithms or any searches they may make.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Lack of age restrictions on aerosol products and other products containing butane/propane propellant
Wider context from the report “1. No Age Restriction
The age restriction on the purchase of butane for refilling cigarette lighters (and the like) is 18 years of age. I understand the legislation is primarily aimed at preventing the misuse of butane.
The age restriction on the purchase of aerosol paints is 16 years of age. I understand that the legislation is aimed at reducing incidents of graffiti and preventing the misuse of butane/propane - ████████ as above.
There is no age restriction on the purchase of aerosol ████████ or other products containing butane/propane as the propellant, ████████ yet their misuse is as equally dangerous.
An age restriction on such products would also likely heighten parental awareness of the dangers of such products.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Failure to control toxic social media algorithms
Wider context from the report “3. Social media content and access
The posting of challenges such as those listed above, and no doubt others, on social media platforms will continue to take the lives of young, impressionable and/or vulnerable children/teenagers unless the platform providers take responsibility fortheir content and/or toxic algorithms either voluntarily or through Government action. The former seems unlikely.
Further the age restriction of 13 years for most social media platforms appears to have been determined in relation to data protection laws rather than of the nature of the content to which they will be exposed, again via any toxic algorithms or any searches they may make.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Age restrictions for social media platforms failing to account for hazardous content exposure
Wider context from the report “3. Social media content and access
The posting of challenges such as those listed above, and no doubt others, on social media platforms will continue to take the lives of young, impressionable and/or vulnerable children/teenagers unless the platform providers take responsibility fortheir content and/or toxic algorithms either voluntarily or through Government action. The former seems unlikely.
Further the age restriction of 13 years for most social media platforms appears to have been determined in relation to data protection laws rather than of the nature of the content to which they will be exposed , again via any toxic algorithms or any searches they may make.
” Open source report
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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 with Ofcom to track the impact of the Online Safety Act and respond to emerging online risks.
Verbatim wording from the response “The government’s mission is clear: children must grow up safe, protected, and free from online harms. I will work relentlessly across government, alongside other Secretaries of State, to prevent tragedies like this from ever happening again. The Online Safety Act is a critical tool in achieving that goal. The protections outlined above are now fully in force, and we are already seeing real tangible improvements in how children experience the online world. But let me be absolutely clear—this is only the beginning. These protections are a foundation from which we will build on if required. My department is working closely with Ofcom to track the impact of the Act, and their flexible approach means we can respond quickly to new and emerging risks. If further action is needed, I will not hesitate to strengthen child safety measures.” Source location Response from Department for Science, Innovation and Technology
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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 enforcing platforms’ Online Safety Act duties, including where services fail to comply with information notices.
Verbatim wording from the response “If a platform fails to respond to a Notice, Ofcom can take tough enforcement action - including fines of up to 10% of the companies' qualifying worldwide revenue or £18 million, whichever is greater. I expect Ofcom to use all its enforcement powers to hold platforms accountable where they are failing to meet their duties under the OSA, including in these circumstances.” Source location Response from Department for Science, Innovation and Technology
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Concerns raised 1 Online availability of suicide methods and concealment advice View source
Responses linked to these concerns
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AI-generated summary
Rhiannon Auriol Mary 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
Rhiannon Auriol Mary Williams, aged 24, died by suicide following prolonged suicidal thoughts and worsening mental health. The inquest recorded the medical cause of death as asphyxia due to combined drug toxicity, neck ligature and submersion. The principal concern was that an online suicide forum and a social media platform provided information and advice about methods of suicide, concealing suicidal intentions and misleading professionals and family members.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Online availability of suicide methods and concealment advice
Wider context from the report “Rhiannon accessed an online ‘suicide forum’ where she was able to access information on how to take her own life and where she obtained advice/information on misleading professionals and her family as to her thoughts and intentions . Rhiannon also accessed a social media platform to obtain information about the method Rhiannon used to take her own life . A similar concern was raised by Patricia Harding Senior Coroner for Central and South East Kent in a Prevent Future Death report of 2019 arising a similar concern in respect of ‘suicide forums’. The response from the Department for Digital, Culture, Media & Sport of 14 January 2020 referred to The Online Harms White Paper. I am aware of The Online Safety Act 2023 and also BBC reporting -https://www.bbc.co.uk/news/uk-67082224 - touching upon whether this Act is in fact sufficient to deal with the risks posed by ‘suicide websites’ . I am concerned about the risk to life posed by the website and social media platform considered in this inquest and so draw them to your attention.
” Open source report
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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 Continue examining ways to extend protections under the Online Safety Act while maintaining focus on swift implementation.
Verbatim wording from the response “This government has committed to tackling suicide and will continue to look at ways we can extend protections under the Act, while maintaining our focus on swift implementation. Alongside this, officials from my department continue to work closely with officials from The Department of Health and Social Care (DHSC), who coordinate the government’s approach to preventing suicides and improving people’s mental health, and lead on the Suicide Prevention Strategy for England. The Strategy identified online safety as a priority area for action and committed to tackling harmful suicide and self-harm content. In addition, the Strategy proposes targeted support for priority groups such as children and young people.” Source location Response from Department for Science, Innovation and Technology
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with Ofcom to implement the Online Safety Act quickly and effectively.
Verbatim wording from the response “As you reference in your report, the Online Safety Act (the ‘Act’) received Royal Assent in October 2023. The Act lays the foundation for strong protections against illegal content for all users and harmful material for children, and the government is committed to working with Ofcom, the independent regulator, to ensure it is implemented quickly and effectively.” Source location Response from Department for Science, Innovation and Technology
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prosecution decisions for encouraging or assisting suicide belong to the Crown Prosecution Service after police investigation.
Verbatim wording from the response “As the Act is a regulatory framework, I turn first to the relevant criminal law in this area (which is the responsibility of the Ministry of Justice). As you will be aware, under section 2(1) of the Suicide Act 1961 (the responsibility of the Ministry of Justice) it is an offence for a person to do an act capable of encouraging or assisting the suicide or attempted suicide of another person, with the intention that their act will encourage or assist suicide or an attempt at suicide. The criminal offence has a high threshold to avoid criminalising people who are expressing suicidal feelings and those offering them support, by, for example, sharing their own experiences. Whether a prosecution for encouraging or assisting suicide can be brought is a matter for the Crown Prosecution Service following a police investigation.” Source location Response from Department for Science, Innovation and Technology
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Criminal law concerning encouraging or assisting suicide is the responsibility of the Ministry of Justice.
Verbatim wording from the response “As the Act is a regulatory framework, I turn first to the relevant criminal law in this area (which is the responsibility of the Ministry of Justice). As you will be aware, under section 2(1) of the Suicide Act 1961 (the responsibility of the Ministry of Justice) it is an offence for a person to do an act capable of encouraging or assisting the suicide or attempted suicide of another person, with the intention that their act will encourage or assist suicide or an attempt at suicide. The criminal offence has a high threshold to avoid criminalising people who are expressing suicidal feelings and those offering them support, by, for example, sharing their own experiences. Whether a prosecution for encouraging or assisting suicide can be brought is a matter for the Crown Prosecution Service following a police investigation.” Source location Response from Department for Science, Innovation and Technology
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17 Dec 2024 Susan Marie Karakoc · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 3 Search engines readily returning websites selling potentially fatal prescription medications View source Failure of prescription medication supply-chain legitimacy monitoring to prevent ready online supply View source Failure of systems to detect criminal medication supply enterprises and alert relevant authorities View source
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AI-generated summary
Susan Marie Karakoc · 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
Susan Marie Karakoc collapsed at home on 1 December 2023 and died in hospital the following day after suffering a hypoxic brain injury. The report states that she obtained prescription medications from online sources selling medicines off-label, and that toxicological examination identified toxicity associated with the chain of events leading to her death. Concerns included the ready availability of such websites through search engines, inadequate monitoring of online medication supply chains, and ineffective detection of financial services supporting criminal enterprises.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Search engines readily returning websites selling potentially fatal prescription medications
Wider context from the report “1. There is evidence of search engines readily returning websites which sell prescription medications , including those that sell highly addictive sleeping tablets and painkillers which can and do cause fatalities . I am concerned how readily search engines return websites such as these ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Failure of prescription medication supply-chain legitimacy monitoring to prevent ready online supply
Wider context from the report “2. I am concerned that the current system for monitoring the legitimacy of supply chains for medications available in England and Wales via prescription is not preventing the ready supply of such medications online ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Failure of systems to detect criminal medication supply enterprises and alert relevant authorities
Wider context from the report “3. There is evidence that banks form a legitimate part of the supply chain, and that this is crucial to the functioning of these criminal enterprises. I am concerned that the current system for detecting such criminal enterprises and alerting the relevant authorities is not effective .
” Open source report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issues concerning medicines and healthcare products are assigned to the Medicines and Healthcare products Regulatory Agency, which provided a separate response.
Verbatim wording from the response “Some of the key issues of concern that you raise in your report are within the remit of The Medicines and Healthcare Products Regulatory Agency, and I understand that they have provided a separate response. As the Secretary of State for Science, Innovation and Technology I am responsible for the Online Safety Act 2023 (‘the Act’) and will respond to the issues raised in this report as per my department’s remit. My department has been taking steps to tackle criminal activity online through the Act, which received Royal Assent in October 2023.” Source location Response from DSIT
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30 Jul 2024 Bethany Paige Langton · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 6 Continued public availability of online guidance on sourcing and using the substance for suicide View source Continued ease of public availability of the substance View source Failure to require explanation of purchasers’ intended use of the substance View source Lack of business awareness that the substance is being obtained for suicide View source Lack of a system for prompt detection and removal of websites providing guidance on sourcing and using the substance for suicide View source Failure to use end-user certification or licensing to track distribution of the substance View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Bethany Paige Langton · 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
Bethany Paige Langton, aged 22, was discovered deceased in her bedroom on 18 February 2023 after deliberately ingesting a substance sourced online with the intention of causing her death. The principal concerns were the substance’s easy online availability, limited awareness among businesses that it could be obtained for suicide, and the continued availability of online guidance about sourcing and using it for that purpose.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Continued public availability of online guidance on sourcing and using the substance for suicide
Wider context from the report “3. Beth used the internet to research how to source and use ████████ to bring about her death. She followed that guidance meticulously. That same guidance was still readily available on the internet at the time of her inquest , although I believe it might now have been removed. What system is in place to ensure that such websites are detected promptly and made unavailable to the public in a timely fashion?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Continued ease of public availability of the substance
Wider context from the report “1. The continued ease of availability of ████████ to members of the public.
The substance is lethal when ingested, even in relatively small quantities. It’s use in suicide is increasing. The substance is readily available to purchase online without the need for any explanation of the purchaser’s intended use for the substance, or an end user certificate/licence to track where it is being distributed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Failure to require explanation of purchasers’ intended use of the substance
Wider context from the report “1. The continued ease of availability of ████████ to members of the public.
The substance is lethal when ingested, even in relatively small quantities. It’s use in suicide is increasing. The substance is readily available to purchase online without the need for any explanation of the purchaser’s intended use for the substance , or an end user certificate/licence to track where it is being distributed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Lack of business awareness that the substance is being obtained for suicide
Wider context from the report “2. Lack of awareness amongst businesses that the substance is being obtained for this purpose.
The company who supplied Beth with the ████████ used in her death, had no idea that the substance might be sourced by individuals for this purpose . Had they have been aware of the risk, they would likely have improved systems for investigating the intended use, or would have stopped offering the item for sale to individuals, as they have now done so.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for prompt detection and removal of websites providing guidance on sourcing and using the substance for suicide
Wider context from the report “3. Beth used the internet to research how to source and use ████████ to bring about her death. She followed that guidance meticulously. That same guidance was still readily available on the internet at the time of her inquest, although I believe it might now have been removed. What system is in place to ensure that such websites are detected promptly and made unavailable to the public in a timely fashion?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Failure to use end-user certification or licensing to track distribution of the substance
Wider context from the report “1. The continued ease of availability of ████████ to members of the public.
The substance is lethal when ingested, even in relatively small quantities. It’s use in suicide is increasing. The substance is readily available to purchase online without the need for any explanation of the purchaser’s intended use for the substance, or an end user certificate/licence to track where it is being distributed .
” Open source report
18 Jul 2024 Deborah Jane Cooper · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 3 Exclusion of provider content from online safety legislation when Amazon UK directly offers suicide-instruction publications through its own marketplace View source Failure of criminal penalties to substantively dissuade limited companies from marketing suicide-instruction publications View source Direct marketing and supply of a publication providing instructions and advice on methods of ending one's life View source
Responses linked to these concerns
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AI-generated summary
Deborah Jane Cooper · 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
Deborah Jane Cooper, aged 61, was found dead at her home after apparatus apparently constructed using instructions from an internet publication was found at the scene, alongside notes indicating an intention to end her life. The principal concern was that the publication, which provided instructions for making the apparatus, was available for direct sale by Amazon UK, with an apparent legislative gap regarding the effectiveness of measures to prevent such material being marketed to the public and children.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Exclusion of provider content from online safety legislation when Amazon UK directly offers suicide-instruction publications through its own marketplace
Wider context from the report “There are 2 issues that are of concern to me both of which leave me with the concern that there appears to be nothing in the legislative arsenal to substantively dissuade Amazon UK from marketing this publication to members of the public and children, if supplied direct from their warehouse. Those concerns are based on :-
a. whilst there may be an offence under the Suicide Act 1961 as amended by the Coroners’ and Justice Act 2009 to include a limited company the penalty for such an offence was not changed and it remains as imprisonment, and you cannot imprison a limited company;
b. Having regard to the response from Ofcom (copy attached for ease of reference), they have made it clear in paragraph 4 that where “Amazon UK itself directly offers a product for sale via its own marketplace, that will be provider content (which is not in scope of the OSA) ….. I have additionally enclosed with this letter a copy taken today from the Amazon website which clearly shows that Amazon UK are directly offering this particular book for sale via its own marketplace.
There therefore seems to be a significant gap in the legislation to stop material like this being directly marketed by an organisation , in this case by Amazon UK, utilising its own marketplace. I fully acknowledge that if Amazon were marketing this on behalf of a third party seller, then that would be covered by the online safety legislation but that does not appear to be the case here and this book is being provided directly by the Amazon UK Warehouse.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Failure of criminal penalties to substantively dissuade limited companies from marketing suicide-instruction publications
Wider context from the report “There are 2 issues that are of concern to me both of which leave me with the concern that there appears to be nothing in the legislative arsenal to substantively dissuade Amazon UK from marketing this publication to members of the public and children, if supplied direct from their warehouse. Those concerns are based on :-
a. whilst there may be an offence under the Suicide Act 1961 as amended by the Coroners’ and Justice Act 2009 to include a limited company the penalty for such an offence was not changed and it remains as imprisonment, and you cannot imprison a limited company ;
b. Having regard to the response from Ofcom (copy attached for ease of reference), they have made it clear in paragraph 4 that where “Amazon UK itself directly offers a product for sale via its own marketplace, that will be provider content (which is not in scope of the OSA) ….. I have additionally enclosed with this letter a copy taken today from the Amazon website which clearly shows that Amazon UK are directly offering this particular book for sale via its own marketplace.
There therefore seems to be a significant gap in the legislation to stop material like this being directly marketed by an organisation, in this case by Amazon UK, utilising its own marketplace. I fully acknowledge that if Amazon were marketing this on behalf of a third party seller, then that would be covered by the online safety legislation but that does not appear to be the case here and this book is being provided directly by the Amazon UK Warehouse.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Direct marketing and supply of a publication providing instructions and advice on methods of ending one's life
Wider context from the report “I indicated earlier in my first Regulation 28 Report that I felt that duty had arisen in this case when I discovered the same publication that I believe was used by Deborah to provide instructions as to how to put a ████████ generator together with a view to ending her life, that such a book is also freely available on the open market on Amazon.co.uk website and supplied directly by Amazon UK . I was concerned that the marketing and supply of such a book giving such clear instructions and advice as regards different methods for an individual to end one's life is of the utmost concern as is the regulation as regards the supply of such publications whose sole purpose is to provide information to those contemplating on ending their lives.
” Open source report
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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 There is no legislative sentencing gap because the Crown Court can impose a fine on a company convicted under the Suicide Act 1961.
Verbatim wording from the response “Now I will address the two specific issues you raise in your letter, the first of which sets out your concern that a limited company cannot be imprisoned under the Suicide Act 1961 as amended by the Coroners’ and Justice Act 2009. Whilst the Suicide Act 1961 does not itself provide for a penalty other than imprisonment, under section 120 of the Sentencing Act 2020 the Crown Court has a general power to impose a fine on an offender convicted on indictment so there is no legislative gap in terms of sentencing if a company were to be convicted of an offence under the 1961 Act. The Suicide Act 1961 falls within the remit of the Ministry of Justice, should you have any further questions on this.” Source location Response from Science Innovation and Technology
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Online Safety Act does not prevent adults accessing legal suicide and self-harm content because some content may provide support.
Verbatim wording from the response “The Online Safety Act does not prevent adult users from accessing legal suicide and self-harm content, regardless of whether it is user generated content or provider content. In some cases, such content may be trying to provide support to those in need and this is therefore a complicated area to regulate. To be clear, I am not saying that ████████ is such a book.” Source location Response from Science Innovation and Technology
Open published response
Concerns raised 2 Online facilitation of UK home delivery of equipment for ending life View source Public availability of step-by-step online instructions for ending life View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Guy Douglas Scotcheford · 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
Guy Scotcheford had a long history of mental health problems and chronic suicidal ideation. He was found deceased at home in a bath on 1 July 2023, and the cause of death was recorded as asphyxiation, with the conclusion of suicide. The report raised concern that an active website provided practical instructions for ending life, including a link to a company supplying relevant equipment for home delivery.
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. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Online facilitation of UK home delivery of equipment for ending life
Wider context from the report “It was clear from the evidence of the investigating officer that the website (████████) is still active and from this website a████████████████████████████████" can be downloaded. This document gives a direct link to a company from which ████████ can be purchased in the UK and home delivered. The police investigation determined that this named company did receive and supply that order. The downloaded document provides step by step instruction on how to end your life with specific advice and direction on the use of certain equipment.
The investigating officer made a recent internet search of this website which states that it provides practical DIY information to enable readers to take control over their own life and death. This website is available to anyone to access online.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Public availability of step-by-step online instructions for ending life
Wider context from the report “It was clear from the evidence of the investigating officer that the website (████████) is still active and from this website a████████████████████████████████" can be downloaded. This document gives a direct link to a company from which ████████ can be purchased in the UK and home delivered. The police investigation determined that this named company did receive and supply that order. The downloaded document provides step by step instruction on how to end your life with specific advice and direction on the use of certain equipment.
The investigating officer made a recent internet search of this website which states that it provides practical DIY information to enable readers to take control over their own life and death. This website is available to anyone to access online.
” Open source report
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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 Raise nitrogen-related concerns with the Concerning Methods Working Group and suggest engaging UK sellers to minimise harm.
Verbatim wording from the response “As leaders of the Suicide Prevention Strategy, officials from the Department for Health & Social Care (DHSC) lead a Concerning Methods Working Group to raise awareness of and tackle access to emerging methods of suicide. Deaths using nitrogen are monitored routinely as part of this. The working group involves representatives from the voluntary community and social enterprise sector, police, academics and the NHS, as well as government departments including Department of Science, Innovation and Technology. DSIT officials will raise the concerns in your letter around Nitrogen with this group and suggest that engagement with UK sellers is undertaken to raise awareness of and minimise the risk of harm to individuals.” Source location Response from Department for Science, Innovation & Technology
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 The Online Safety Act does not permit preventing adults from accessing legal suicide or self-harm content.
Verbatim wording from the response “As previously explained, the Online Safety Act does not prevent adult users from accessing legal suicide and self-harm content. In some cases, such content may be trying to provide support to those in need and this is therefore a complicated area to regulate. To be clear, I am not saying that ████████ is such a book.” Source location Response from Department for Science, Innovation & Technology
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 Police investigations, CPS prosecution decisions and courts determine whether authors or distributors have committed an offence.
Verbatim wording from the response “Whether a prosecution for encouraging or assisting suicide can be brought is a matter for the Crown Prosecution Service following a police investigation. The CPS policy on assisted suicide¹ sets out the factors which prosecutors in England and Wales will consider, in addition to those already outlined in the Code for Crown Prosecutors, when deciding whether it is in the public interest to prosecute in cases of encouraging or assisting suicide.” Source location Response from Department for Science, Innovation & Technology
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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 Enforcement of existing suicide-related offences falls outside the government's functions.
Verbatim wording from the response “The issue therefore is whether the authors or distributors of ████████ or similar books are committing an offence. However, the enforcement of existing offences is not for the government, but for the police and the Crown Prosecution Service and it is ultimately for the courts to decide if an offence has been committed. As you are aware, relevant criminal offences have a high threshold to avoid criminalising people who are expressing suicidal feelings and those offering them” Source location Response from Department for Science, Innovation & Technology
Open published response
28 Dec 2023 Adrian Brendan GALLAGHER · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 3 Availability of suicide-assistance material online View source Failure to conduct age and identity checks before purchase View source Online sale of drugs for ending life View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Adrian Brendan GALLAGHER · 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
Adrian Gallagher was found deceased in bed on 10 November 2017 after being admitted to Hollins Park Hospital and receiving periods of unsupervised leave. His death was due to an intentional overdose and the inquest concluded that it was suicide. Concerns included the online availability of materials and drugs that could assist suicide, limited age and identity checks, and access by vulnerable mental health patients.
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. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Availability of suicide-assistance material online
Wider context from the report “████████ is available to anyone to purchase online, directly from the company. The company appears to have some link to the UK as there is a UK helpline number. The ████████ appears to provide step by step instruction on how to end your life using certain methods, including how to make the death appear to be due to natural causes and therefore avoid referral to the coroner. Whilst the introduction suggests it is aimed at those who are elderly and long-term suffering, there is also reference to suicide for other reasons within the book and is likely to appear to vulnerable mental health patients.
According to the evidence of the police officer, you can also buy drugs to end your life through this website.
The only check on age and ID appears to be after a purchase, to allow you access to online forums where you can get further advice on best methods.
The ████████ has been banned in Australia (and possibly other countries) as it is deemed to encourage/ assist in suicide.
The ████████, in some format, is also available on Amazon (and I am writing to Amazon directly to flag this).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct age and identity checks before purchase
Wider context from the report “████████ is available to anyone to purchase online, directly from the company. The company appears to have some link to the UK as there is a UK helpline number. The ████████ appears to provide step by step instruction on how to end your life using certain methods, including how to make the death appear to be due to natural causes and therefore avoid referral to the coroner. Whilst the introduction suggests it is aimed at those who are elderly and long-term suffering, there is also reference to suicide for other reasons within the book and is likely to appear to vulnerable mental health patients.
According to the evidence of the police officer, you can also buy drugs to end your life through this website.
The only check on age and ID appears to be after a purchase , to allow you access to online forums where you can get further advice on best methods .
The ████████ has been banned in Australia (and possibly other countries) as it is deemed to encourage/ assist in suicide.
The ████████, in some format, is also available on Amazon (and I am writing to Amazon directly to flag this).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Science, Innovation and Technology; that does not assign responsibility.
PFD Monitor interpretation Online sale of drugs for ending life
Wider context from the report “████████ is available to anyone to purchase online, directly from the company. The company appears to have some link to the UK as there is a UK helpline number. The ████████ appears to provide step by step instruction on how to end your life using certain methods, including how to make the death appear to be due to natural causes and therefore avoid referral to the coroner. Whilst the introduction suggests it is aimed at those who are elderly and long-term suffering, there is also reference to suicide for other reasons within the book and is likely to appear to vulnerable mental health patients.
According to the evidence of the police officer, you can also buy drugs to end your life through this website.
The only check on age and ID appears to be after a purchase, to allow you access to online forums where you can get further advice on best methods.
The ████████ has been banned in Australia (and possibly other countries) as it is deemed to encourage/ assist in suicide.
The ████████, in some format, is also available on Amazon (and I am writing to Amazon directly to flag this).
” Open source report
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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 Act framework.
Verbatim wording from the response “Every suicide is a tragedy, and my department is working with other departments to tackle the deeply concerning issue of vulnerable users gaining access to harmful content online, whether on services that are in scope of the act or otherwise. The act introduces much needed protections for users and we are working closely with Ofcom to ensure that the implementation of the framework is as quick as possible.” Source location Response from Department for Science, Innovation and Techonology
Open published response
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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 with other government departments to tackle vulnerable users’ access to harmful online content.
Verbatim wording from the response “Every suicide is a tragedy, and my department is working with other departments to tackle the deeply concerning issue of vulnerable users gaining access to harmful content online, whether on services that are in scope of the act or otherwise. The act introduces much needed protections for users and we are working closely with Ofcom to ensure that the implementation of the framework is as quick as possible.” Source location Response from Department for Science, Innovation and Techonology
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations