Concerns raised 1 Online availability of suicide methods and concealment advice 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
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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× 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 Ofcom; 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 Run three sector-wide compliance programmes monitoring providers’ illegal-content risk-assessment and record-keeping duties.
Verbatim wording from the response “We expect our early enforcement action to focus on ensuring services are adequately assessing risk and putting in place the measures that will be most impactful in protecting users, especially children, from serious harms such as those relating to CSAM, pornography and illegal suicide content. To date we have launched three sector-wide compliance programmes as the illegal content duties have come into force to monitor whether providers are complying with their illegal content risk assessment duties and record keeping duties under the Act. We are also taking targeted action against specific services, the first of which is directly relevant to the matters of concern included in the Report.” Source location Response from OFCOM
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 Engage TikTok on the suicide-content and child-safety issues raised in the Report.
Verbatim wording from the response “Evidence, like the information included in the Report, helps inform our supervisory engagement and prioritisation, such as which providers we should be engaging with and what we should focus our engagement on. We have been actively engaging with TikTok since 2022 under the Video Sharing Platform (VSP) regime (a pre-cursor to the Online Safety Act). One of our key priorities under the VSP regime has been to ensure that children are protected from finding and viewing age-inappropriate videos. Based on the information included in the Report, we will be engaging with TikTok on some of the issues you have raised in your Report.” Source location Response from OFCOM
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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 Operate a dedicated taskforce to bring smaller, riskier online services, including suicide discussion forums, into compliance.
Verbatim wording from the response “In addition to our broader supervisory programme, we have a dedicated taskforce dealing with ‘small but risky services’. The taskforce’s focus is bringing smaller, riskier services into compliance with their duties under the Act. For the purposes of this work the services in question are those which:” Source location Response from OFCOM
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 Operate Supervision teams that engage selected high-risk services to assess their safety measures and drive timely compliance improvements.
Verbatim wording from the response “In addition to our formal powers to ensure that service providers comply with their duties under the Act, we have established Supervision teams which are already actively engaging with selected service providers to drive compliance with the Act. The providers we have chosen to supervise are those that pose particular risk, either because of their size, functionality or because of the nature of the service. This includes the largest services such as popular social media platforms, search services, messaging and gaming services, as well as smaller services that present particular risk due to the” Source location Response from OFCOM
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 Publish the Illegal Harms Statement, final Illegal Harms Codes of Practice and related guidance.
Verbatim wording from the response “On 16 December 2024 we published our statement on protecting people from illegal harms online (‘Illegal Harms Statement’) which included our final Illegal Harms Codes of Practice and guidance. On the same day, the Codes were submitted to the Secretary of State who laid them in Parliament for 40 days. Concurrently, regulated service providers were required to undertake their illegal content risk assessments. Following approval by Parliament, the Codes came into force on 17 March 2025. This means the illegal harms safety duties are now enforceable, and we can take enforcement action against providers that are not complying with their illegal harms duties. We can begin investigations and – following the conclusion of those – impose sanctions if we find that services are not compliant with these duties.” Source location Response from OFCOM
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 Investigate the identified suicide forum’s compliance with safety measures, illegal-harms risk-assessment and information-request duties, and provide regular website updates.
Verbatim wording from the response “In line with the approach outlined above, on 9 April 2025, we opened an investigation into ████████. The investigation will examine whether there are reasonable grounds to believe that this service provider has failed, or is failing, to comply with its duties to:” Source location Response from OFCOM
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 Online services, rather than Ofcom, are legally responsible for assessing and mitigating risks and removing illegal suicide content under the Act.
Verbatim wording from the response “• Duties on user-to-user and search service providers to assess the risks their services pose to users in relation to illegal content (including illegal suicide content); and content that is harmful to children (including content that encourages, promotes or provides instructions for suicide), and take steps to mitigate and manage those risks;” Source location Response from OFCOM
Open published response
14 Nov 2024 Miranda Emilia Avanzi · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Ready availability of information providing instructions for ending one’s own life View source Lack of useful age verification on websites providing suicide guides 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
Miranda Emilia Avanzi · 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
Miranda Emilia Avanzi was found unresponsive at home on 9 July 2024, partially suspended by a ligature, and her death was verified shortly afterwards. The principal concern was the ready availability online of detailed guides, including pictures and diagrams, giving instructions on ending one’s life by partial hanging, with limited age verification on some sites.
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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 Ofcom; that does not assign responsibility.
PFD Monitor interpretation Ready availability of information providing instructions for ending one’s own life
Wider context from the report “The police found a printout from a blog post close to Ms Avanzi, while investigating the initial circumstances of her death. That 10-page document contains a step-by-step guide (with the inclusion of pictures and diagrams) on how to ‘succeed’ in ending one’s life by ‘partial hanging’. It was clear that this guide had been followed in the circumstances of this case.
While it is not obvious which website or forum this particular guide came from, it does cite numerous sources including ████████ and ████████. Just a basic search on Google or other search engines, reveals a significant number of forums and blogs, where users are able to obtain all manner of guides to completing suicide. Many of these sites have no, or no useful requirement for any type of age verification. The search engine suggests, at the top of the page, that help is available by dialling 999, which would appear to be an acknowledgement that the content resulting from the search is likely to be concerning and that person undertaking the search is likely already highly vulnerable.
I am concerned that the ready availability of such information, that provides clear instructions and advice for individuals wanting to end their own life at their own hands is of the utmost concern.
” 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 Ofcom; that does not assign responsibility.
PFD Monitor interpretation Lack of useful age verification on websites providing suicide guides
Wider context from the report “The police found a printout from a blog post close to Ms Avanzi, while investigating the initial circumstances of her death. That 10-page document contains a step-by-step guide (with the inclusion of pictures and diagrams) on how to ‘succeed’ in ending one’s life by ‘partial hanging’. It was clear that this guide had been followed in the circumstances of this case.
While it is not obvious which website or forum this particular guide came from, it does cite numerous sources including ████████ and ████████. Just a basic search on Google or other search engines, reveals a significant number of forums and blogs, where users are able to obtain all manner of guides to completing suicide. Many of these sites have no, or no useful requirement for any type of age verification. The search engine suggests, at the top of the page, that help is available by dialling 999, which would appear to be an acknowledgement that the content resulting from the search is likely to be concerning and that person undertaking the search is likely already highly vulnerable.
I am concerned that the ready availability of such information, that provides clear instructions and advice for individuals wanting to end their own life at their own hands is of the utmost concern.
” 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 Produce the Illegal Harms Register of Risks, risk profiles and risk-assessment guidance for regulated services.
Verbatim wording from the response “Illegal Harms – Assessing risks” Source location Response from OFCOM
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 Publish Illegal Content Judgements Guidance explaining how services can identify illegal suicide content.
Verbatim wording from the response “We also published Ofcom’s Illegal Content Judgements Guidance (ICJG) on how services can identify illegal suicide content, as discussed further below. The ICJG provides guidance to user-to-user and search service providers on how they may identify illegal content (i.e. content which may reasonably be inferred to amount to a relevant offence) including under Section 2 of the Suicide Act 1961 (‘the suicide offence’). The offence of encouraging or assisting suicide is a priority offence under the Act.” Source location Response from OFCOM
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 Publish the final Illegal Harms Statement, including the Illegal Harms Codes of Practice and guidance.
Verbatim wording from the response “As set out above, we published our statement on protecting people from illegal harms online (‘Illegal Harms Statement’) which includes our final Illegal Harms Codes of Practice and guidance, on 16 December 2024. The Codes have been submitted to the Secretary of State who has laid them in Parliament for 40 days. Concurrently, regulated service providers have until 16 March 2025 to undertake their illegal content risk assessments which we explain in more detail below. Following approval by Parliament, the Codes will come into force 21 days after they have been issued, which we expect to be from 17 March 2025. At this time, the illegal harms safety duties become enforceable, and we can begin investigations and – following the conclusion of those – impose sanctions if we find that services are not compliant with these duties.” Source location Response from OFCOM
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 Continue regulatory supervision and direct work with high-risk services to promote compliance and improve protection from illegal or child-harmful suicide material.
Verbatim wording from the response “The duties in the Act are not yet enforceable, however we have already been encouraging service providers in scope of the Act to take meaningful steps to improve safety on their platforms. To this end, we are committed to driving industry improvements by engaging with the riskiest services via ongoing ‘regulatory supervision.’ We also have a dedicated team for identifying, prioritising and escalating emerging issues, particularly on services where we do not have an existing supervisory relationship, which we call the Triage team. The purpose of the Triage team is to ensure Ofcom responds effectively, promptly, and proportionately to new or growing harms and risks, focusing our reactive work on the most harmful issues.” Source location Response from OFCOM
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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 Ofcom cannot yet enforce the new online-safety duties because required implementation steps and Parliamentary approval remain outstanding.
Verbatim wording from the response “Although the Act is now law, there are numerous procedural steps needed for the new regime to be fully implemented, and these steps need to be completed before services’ legal duties under the regime – and Ofcom’s ability to enforce those duties – come into force. These steps include:” Source location Response from OFCOM
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 Regulated online services are responsible for assessing and mitigating suicide-content risks and removing or reducing illegal content.
Verbatim wording from the response “• Imposes a number of duties on those regulated services, in order to improve their systems and processes to ensure the safety of their users. These include:
o Duties on search services and user-to-user services to assess the risks their services pose to users in relation to illegal content (including illegal suicide content, which we address in more detail below), and content that is harmful to children (including content that encourages, promotes or provides instruction for suicide), and take steps to mitigate and manage those risks.
o Duties on search services to minimise the risk of individuals encountering illegal content (including illegal suicide content) and children from encountering content” Source location Response from OFCOM
Open published response
5 Mar 2024 Isabella Shere · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Related-question recommendations encouraging further consumption of the material View source Pop-up question functionality detracting from users appreciating the seriousness of the subject matter View source Upvoting functionality detracting from users appreciating the seriousness of the subject matter View source Question-following functionality encouraging further consumption of the material View source Insufficient monitoring and moderation of question-and-answer content View source Failure to restrict children’s access to content without age verification View source See 3 more concerns
Responses linked to these concerns
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AI-generated summary
Isabella Shere · 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
Isabella Shere died at home in Lewisham, London, on 2 February 2023, aged 14. The inquest concluded that her death was suicide, with the medical cause recorded as asphyxia caused by hanging. The concerns included the availability and accessibility of information relating to methods of ending life on Quora, related content and user-engagement features encouraging further consumption, and insufficient monitoring or moderation.
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× 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 Ofcom; that does not assign responsibility.
PFD Monitor interpretation Related-question recommendations encouraging further consumption of the material
Wider context from the report “(4) When viewing content ████████, a list of related questions is displayed, suggesting further similar content to users and encouraging further consumption of this material .
” 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 Ofcom; that does not assign responsibility.
PFD Monitor interpretation Pop-up question functionality detracting from users appreciating the seriousness of the subject matter
Wider context from the report “(6) There is an upvoting function which allows users to vote on the most useful answers to questions ████████. There is pop up question which can appear which asks ████████████████████████████████████████████████████████████████████
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████████ Both of these functions detract from user appreciating the seriousness of the subject matter that is being consumed.
” 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 Ofcom; that does not assign responsibility.
PFD Monitor interpretation Upvoting functionality detracting from users appreciating the seriousness of the subject matter
Wider context from the report “(6) There is an upvoting function which allows users to vote on the most useful answers to questions ████████ . There is pop up question which can appear which asks ████████████████████████████████████████████████████████████████████
████████████████████████████████████████████████████████████████████████
████████ Both of these functions detract from user appreciating the seriousness of the subject matter that is being consumed.
” 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 Ofcom; that does not assign responsibility.
PFD Monitor interpretation Question-following functionality encouraging further consumption of the material
Wider context from the report “(5) There is a function to follow questions ████████████████████████ encouraging further consumption of this material .
” 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 Ofcom; that does not assign responsibility.
PFD Monitor interpretation Insufficient monitoring and moderation of question-and-answer content
Wider context from the report “(7) There is not sufficient monitoring and/or moderation of the content of questions/answers in accordance with Quora’s own platform policies. ████████
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” 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 Ofcom; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict children’s access to content without age verification
Wider context from the report “(3) Children are able to access the site through search engines without being required to create an account and access content ████████ without being asked if they are an adult or being required to input their date of birth .
” 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 Publish draft Children’s Safety Codes, Children’s Access Assessments Guidance and Children’s Risk Assessment Guidance through the Protection of Children Consultation.
Verbatim wording from the response “Phase two: Protecting Children We published our consultation Guidance for service providers publishing pornographic content on 5 December 2023. This included draft guidance on age assurance and other duties for services providing pornographic content. Following this, we published our consultation Protecting children from harms online (‘Protection of Children Consultation’) on 8 May 2024. This consultation includes our draft Children’s Safety Codes which set out more than 40 practical steps that services can take to keep children safer online.” Source location 2024-0298 Response from Ofcom
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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 Publish the Protection of Children statement, final guidance and Children’s Safety Codes by the end of April 2025.
Verbatim wording from the response “Services that conclude they are likely to be accessed by children are required to carry out children’s risk assessments. Our Protection of Children statement, including final Children’s Risk Assessment Guidance, will be published in spring 2025. By this point, services will have had three months to complete their first children’s access assessment and determine whether they need to comply with the children’s safety duties.” Source location 2024-0298 Response from Ofcom
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 Publish final Children’s Access Assessments Guidance.
Verbatim wording from the response “We intend to publish our final Children’s Access Assessments Guidance in early 2025. Regulated services, such as Quora, will then have three months to complete children’s access assessments. If they conclude they are likely to be accessed by children, they will need to carry out a children’s risk assessment.” Source location 2024-0298 Response from Ofcom
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 Regulated online services, rather than the regulator, must assess and mitigate risks and implement measures protecting users from illegal and harmful suicide content.
Verbatim wording from the response “• Imposes a number of duties on those regulated services, which focus on improving the systems and processes online services operate to ensure the safety of their users, rather than on the presence of individual pieces of content.” Source location 2024-0298 Response from Ofcom
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 Ofcom cannot enforce the online safety duties until its Codes of Practice receive approval and are brought into force through the statutory process.
Verbatim wording from the response “Although the Act is now law, the duties are not yet in force. The Act requires us to draft Codes of Practice and consult on them before submitting them to the Secretary of State for approval. If approved, the Codes must then be laid before parliament for 40 days. Following approval by Parliament, the Codes will come into force 21 days after they have been issued. We explain our plans to implement the regime (consultation and enforcement timings) for Ofcom’s Illegal Harms Consultation and Protection of Children Consultation below. More information on our approach to implementing the Act can be found in our published Roadmap.” Source location 2024-0298 Response from Ofcom
Open published response
29 Feb 2024 Daniel Mark Edward TUCKER · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 7 Inadequate allocation of named nurses to patients View source Continuing accessibility of an online suicide forum to vulnerable people in the UK View source Failure of 999 call grading to trigger a category 1 ambulance response for confirmed ingestion of a potent poison View source Failure to record the named nurse appointed to each patient View source Failure of clinical and nursing staff to complete and utilise ward-specific risk assessments and care plans View source Inadequate delivery of regular and effective named nurse 1:1 sessions View source Insufficient staff skills and knowledge for encouraging engagement with patients View source See 4 more concerns
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
Daniel Mark Edward TUCKER · 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
Daniel Mark Edward Tucker was detained under the Mental Health Act and admitted to hospital following self-harm and suicidal thoughts, but was discharged on 22 April 2022 despite ongoing concerns about his mental state and risk. He ingested a lethal quantity of a substance later that evening and died. The report identifies concerns about risk assessment and care planning, named-nurse allocation, staff skills in engaging patients, emergency response to confirmed ingestion, and the accessibility of online suicide forums.
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 Ofcom; that does not assign responsibility.
PFD Monitor interpretation Inadequate allocation of named nurses to patients
Wider context from the report “2. Inadequate system of allocating a named nurse to patients and recording the same
I am concerned that, notwithstanding the existence of a clear, appropriate policy requiring the same, the current system of allocating a named nurse and ensuring patients receive regular and effective 1:1 sessions with them are inadequate. I am also concerned that no record is kept of the named nurse appointed to each patient, thus (as in this case) hindering any investigation where issue around the role and actions of that person arises.
The General Manager of Adult Mental Health at the Trust helpfully and frankly acknowledged that the evidence heard at inquest raised questions about the adequacy of the existing system, of which he was not previously aware of. It remains unclear whether Daniel was appointed a Named Nurse who failed to perform that role effectively, or whether there was a failure to appoint such a nurse at all. The General Manager’s view was that under the existing system, it is possible that a named nurse was appointed without their knowledge. While the Ward Manager gave evidence that she would have no confidence Daniel would have known who his named nurse was, even if one was appointed. The inquest heard evidence that named nurse sessions with Daniel during previous admissions had been important opportunities for engagement with staff and had elicited a substantial amount of information pertinent to his risk and treatment. The General Manager assured me that he has already requested an urgent review of the system, but he was unable to provide any further information upon conclusion of the inquest as to what further action, if any, is proposed.
” 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 Ofcom; that does not assign responsibility.
PFD Monitor interpretation Continuing accessibility of an online suicide forum to vulnerable people in the UK
Wider context from the report “1. Continuing accessibility of █████████████████████████████████████████████████████████
Dan was using an online suicide forum, █████████████████████████ Through that forum he was able to engage in discussions with other █████████████████████████ members and obtain information █████████████████████████████████████████████████████████
Notwithstanding the provisions of the Online Safety Act 2023, and apparent attempts to block access to the website, I heard evidence that it remains easily accessible to vulnerable people in the UK . I am concerned that further deaths will occur while this remains the case .
” 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 Ofcom; that does not assign responsibility.
PFD Monitor interpretation Failure of 999 call grading to trigger a category 1 ambulance response for confirmed ingestion of a potent poison
Wider context from the report “1. I am concerned that confirmed ingestion of ████████ during a 999 call does not trigger a category 1 response from the Ambulance Service
Dan ingested ████████ at around 20:30 on 22 April 2022. His friend informed the 999 call handler that he had done so during a first 999 call at 20:39. That call was correctly graded as requiring a category 2 response, as Dan was both conscious and awake. 14 minutes later, at 20:53, Dan collapsed. His friend’s second 999 call was correctly graded as requiring a category 1 response, as Dan had become unconscious, his breathing agon al. The first ambulance crew arrived at 21:04. Dan went into cardiac arrest at approximately 21:24. Consideration was given by the ambulance crew to ‘scoop and run’ to arrange a rendezvous to administer the necessary “drugs to counter ████████”, but this was no considered longer feasible once Dan had gone into cardiac arrest.
The inquest heard evidence from a consultant toxicologist that even in very small quantities ████████ (or ████████) is lethal; it is a potent poison. I understand it is also, tragically, an increasingly common means of suicide. Mental health professionals who gave evidence expressed deep concern at its easy availability and growing popularity for vulnerable people seeking to end their own lives. The expert toxicological evidence indicated that its acute toxic effects can be rapid (as short as 20 minutes after ingestion, depending on dose) and can quickly become irreversible.
This suggests that almost any case involving the ingestion of ████████ or ████████ is likely to be a time critical life-threatening event . Yet it is does not currently fall within that category for the purposes of grading 999 calls, unless the patient is unconscious or not breathing. While there was no evidence that a category 1 response would have prevented Dan’s death, I believe there is a risk that other deaths will occur if ingestion of ████████ continues to require a category 2 response.
” 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 Ofcom; that does not assign responsibility.
PFD Monitor interpretation Failure to record the named nurse appointed to each patient
Wider context from the report “2. Inadequate system of allocating a named nurse to patients and recording the same
I am concerned that, notwithstanding the existence of a clear, appropriate policy requiring the same, the current system of allocating a named nurse and ensuring patients receive regular and effective 1:1 sessions with them are inadequate. I am also concerned that no record is kept of the named nurse appointed to each patient , thus (as in this case) hindering any investigation where issue around the role and actions of that person arises.
The General Manager of Adult Mental Health at the Trust helpfully and frankly acknowledged that the evidence heard at inquest raised questions about the adequacy of the existing system, of which he was not previously aware of. It remains unclear whether Daniel was appointed a Named Nurse who failed to perform that role effectively, or whether there was a failure to appoint such a nurse at all. The General Manager’s view was that under the existing system, it is possible that a named nurse was appointed without their knowledge. While the Ward Manager gave evidence that she would have no confidence Daniel would have known who his named nurse was, even if one was appointed. The inquest heard evidence that named nurse sessions with Daniel during previous admissions had been important opportunities for engagement with staff and had elicited a substantial amount of information pertinent to his risk and treatment. The General Manager assured me that he has already requested an urgent review of the system, but he was unable to provide any further information upon conclusion of the inquest as to what further action, if any, is proposed.
” 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 Ofcom; that does not assign responsibility.
PFD Monitor interpretation Failure of clinical and nursing staff to complete and utilise ward-specific risk assessments and care plans
Wider context from the report “1. A continuing practice/culture of minimising the importance of a ward specific risk assessment and care plan
I am concerned that, notwithstanding the existence of a clear, appropriate policy and significant commendable actions by the Trust since Daniel’s death to address this issue, there remain clinical and nursing staff who do not fully recognise or accept the importance of completing and utilising the required risk assessment and care plan . This suggests there may be a persisting training or cultural issue.
The inquest heard evidence that there was (and remains) a clear and robust policy in place which most staff were aware of. This requires a care plan and risk assessment be initiated upon a patient’s admission, completed within 72 hours of admission and updated as necessary during admission. Further, since Dan’s death, the Trust has gone to considerable and commendable lengths to ensure that care plans and risk assessments are in place in every case and to reinforce the requirements of this guidance within the Nursing team; that team hold primary (but not sole) responsibility for creating and updating the risk assessment and care plan document. I also heard that a recent audit found that all current patients had an appropriate care plan in place. The Ward Manager agreed this is “a basic and fundamental part” of any patient’s care. In spite of all of this, an experienced ward nurse and two psychiatrists (a consultant and a registrar) involved in Dan’s care seemed to minimise the practical importance of the required process and documentation , the latter both suggesting they would not routinely consult it.
” 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 Ofcom; that does not assign responsibility.
PFD Monitor interpretation Inadequate delivery of regular and effective named nurse 1:1 sessions
Wider context from the report “2. Inadequate system of allocating a named nurse to patients and recording the same
I am concerned that, notwithstanding the existence of a clear, appropriate policy requiring the same, the current system of allocating a named nurse and ensuring patients receive regular and effective 1:1 sessions with them are inadequate . I am also concerned that no record is kept of the named nurse appointed to each patient, thus (as in this case) hindering any investigation where issue around the role and actions of that person arises.
The General Manager of Adult Mental Health at the Trust helpfully and frankly acknowledged that the evidence heard at inquest raised questions about the adequacy of the existing system, of which he was not previously aware of. It remains unclear whether Daniel was appointed a Named Nurse who failed to perform that role effectively, or whether there was a failure to appoint such a nurse at all. The General Manager’s view was that under the existing system, it is possible that a named nurse was appointed without their knowledge. While the Ward Manager gave evidence that she would have no confidence Daniel would have known who his named nurse was, even if one was appointed. The inquest heard evidence that named nurse sessions with Daniel during previous admissions had been important opportunities for engagement with staff and had elicited a substantial amount of information pertinent to his risk and treatment. The General Manager assured me that he has already requested an urgent review of the system, but he was unable to provide any further information upon conclusion of the inquest as to what further action, if any, is proposed.
” 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 Ofcom; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff skills and knowledge for encouraging engagement with patients
Wider context from the report “3. Inadequate skills/knowledge/training on how to encourage patients to engage
I am concerned that clinical, nursing and/or support staff may not currently have sufficient skills or knowledge in dealing with patients who appear unable or unwilling to engage with staff and/or treatment .
A psychiatrist not involved in Dan’s care gave evidence about the advice he would have given to colleagues on how to seek to assist a patient who, like Dan, was unwilling or unable to engage with staff: first, identify the likely reasons for the patient’s lack of engagement; second, having regard to those reasons, develop plans and strategies to address the specific barriers identified.
I heard little evidence that either of these steps was followed by any of the staff involved in Dan’s care. One barrier was identified (his previous negative experiences on the ward and wish to be transferred to another ward or hospital) but seemingly forgotten after an initial transfer request to the Bed Management team, which was not then followed up. Even with the benefit of hindsight, the doctors, nurses and healthcare assistants involved in Dan’s care seemed unable to offer any insight into the reasons for his difficulties engaging beyond his diagnosis of EUPD or articulate any strategies or techniques that might have helped him overcome them .
” 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 Submit final illegal-harms Codes of Practice to the Secretary of State and publish associated guidance.
Verbatim wording from the response “The Act requires Ofcom to submit our Codes of Practice on illegal harms to the Secretary of State and to publish associated guidance within 18 months of Royal Assent. Once we issue our statement, services will have three months to undertake their illegal content risk assessments. At this point we” Source location Response from Ofcom
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 directly with online services to promote compliance with online-safety duties.
Verbatim wording from the response “We are committed to working with industry to ensure compliance with these duties, and to this end our draft illegal harms Codes of Practice include specific measures which we propose would allow services to meet their duties in an effective and proportionate manner. We will ensure that through consulting on our proposals we seek input and engagement with external experts. We will also work directly with services to promote compliance, including – where appropriate – through targeted supervision. And where we identify non-compliance, we will not hesitate to take appropriate enforcement action to protect users from harm.” Source location Response from Ofcom
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 Continue regulatory supervision and engage the largest and riskiest online services to promote safety improvements.
Verbatim wording from the response “In the meantime, we are already encouraging in-scope service providers to take meaningful steps to improve safety on their platforms. To this end, we are committed to driving industry improvements by engaging with the largest and riskiest services via continuous ‘regulatory supervision.’” Source location Response from Ofcom
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 Continue monitoring the forum’s accessibility to UK users.
Verbatim wording from the response “Following reports¹ of alleged illegal and harmful suicide content on ████████ Ofcom contacted the service on 7 November 2023, which subsequently announced via its website that UK users would be blocked. On January 8 2024, we contacted the service again to note we were aware that the restrictions appeared to no longer be in place. At the time of writing, we are aware that the site is accessible by UK users. This is a situation which we will continue to monitor, but as noted above, Ofcom does not have powers to enforce these duties until the relevant guidance and Codes have been finalised and come into force.” Source location Response from Ofcom
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 Publish draft illegal-content Codes of Practice and Illegal Content Judgements Guidance.
Verbatim wording from the response “We published our illegal content Codes of Practice in draft form alongside our illegal harms consultation.⁶ The proposed measures in our Codes of Practice would require services to, among other things:” Source location Response from Ofcom
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 Issues outside Ofcom’s remit are not addressed in the response.
Verbatim wording from the response “Our response will necessarily focus only on the issues raised in the report which are within Ofcom’s remit, namely, the ‘continuing accessibility of the pro suicide web-forum, ████████with reference to new legal requirements under the Online Safety Act 2023 (‘the Act’).” Source location Response from Ofcom
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 Ofcom cannot enforce online safety duties until the relevant guidance and Codes of Practice are finalised and in force.
Verbatim wording from the response “We are currently in the process of putting in place regulation to implement the Online Safety regime, following the Act coming into force on 26 October 2023. Until the relevant procedural steps outlined below are completed, the duties on regulated services are not yet fully in force. As Ofcom’s enforcement powers are tied to non-compliance with these duties, we will only be able to pursue enforcement action against online services once our Codes of Practice are finalised in 2025. Once” Source location Response from Ofcom
Open published response
19 Dec 2023 Chloe Elizabeth MACDERMOTT · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 6 Lack of prominent signposting to organisations providing suicide-prevention help View source Internet availability and delivery of an unspecified item to individual users in the UK View source Open chatrooms permitting the exchange of information and methods that encourage, assist, counsel or procure suicide View source Failure of effective border and customs controls for delivery of an unspecified item to UK users View source Lack of age or other access restrictions for children, vulnerable teenagers and vulnerable adults View source Failure to effectively remove posts containing details of suicide methods View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Chloe Elizabeth MACDERMOTT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Chloe Elizabeth MACDERMOTT died at home in the early hours of 23 May 2021 after ingesting a substance purchased through Amazon US. The report identifies concerns about online forums encouraging, assisting and counselling suicide, inadequate age restrictions and signposting to help, harmful content not being effectively removed, and the availability and delivery of the product to UK users without effective border or customs controls.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ofcom; that does not assign responsibility.
PFD Monitor interpretation Lack of prominent signposting to organisations providing suicide-prevention help
Wider context from the report “(6) No prominent signposting is in place to organisations from whom help is available to prevent suicide .
” 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 Ofcom; that does not assign responsibility.
PFD Monitor interpretation Internet availability and delivery of an unspecified item to individual users in the UK
Wider context from the report “(9) The availability of ████████ through the internet and its delivery to individual users in the UK with a non-commercial or agricultural use.
” 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 Ofcom; that does not assign responsibility.
PFD Monitor interpretation Open chatrooms permitting the exchange of information and methods that encourage, assist, counsel or procure suicide
Wider context from the report “(3) ████████ is a forum that permits material to be exchanged and reviewed within its open chatrooms whereby suicide is encouraged, assisted, counselled and procured through the provision and exchange of information and methods .
” 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 Ofcom; that does not assign responsibility.
PFD Monitor interpretation Failure of effective border and customs controls for delivery of an unspecified item to UK users
Wider context from the report “(10) The ability for UK users to purchase ████████ through Amazon in the United States and to take delivery in the United Kingdom without effective border and/or custom controls .
” 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 Ofcom; that does not assign responsibility.
PFD Monitor interpretation Lack of age or other access restrictions for children, vulnerable teenagers and vulnerable adults
Wider context from the report “(5) No age or other restrictions are in place to prevent access to children, vulnerable teenagers and vulnerable adults .
” 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 Ofcom; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively remove posts containing details of suicide methods
Wider context from the report “(7) Posts are made by users containing details of methods of suicide without any effective administration to remove such harmful content .
” 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 Publish final Children’s Access Assessment Guidance and the main statement on children’s safety duties.
Verbatim wording from the response “Regulated services will have three months to carry out Children’s Access Assessments after we publish our final Guidance. If they conclude that they are likely to be accessed by children, then they will have to carry out Children’s Risk Assessments. We intend to publish our final Guidance on Children’s Access Assessments in early 2025. Our main statement on the Children’s Safety Duties will follow in Spring 2025. This will allow services to complete their initial Children’s Access Assessments and determine whether they need to comply with the children’s safety duties, before the requirement to carry out Children’s Risk Assessments comes into force.” Source location Response from Ofcom
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 Engage with in-scope services through ongoing regulatory supervision and support them toward compliance.
Verbatim wording from the response “In the meantime, we are already encouraging in-scope service providers to take meaningful steps to improve safety on their platforms. To this end, we are committed to driving industry improvements by engaging with the largest and riskiest services via continuous ‘regulatory supervision.’” Source location Response from Ofcom
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 Publish the final illegal-harms statement and associated guidance after completing the consultation.
Verbatim wording from the response “After Ofcom’s illegal harms consultation and statement” Source location Response from Ofcom
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 Publish the consultation on protecting children, including draft access-assessment, risk-assessment and child-protection materials.
Verbatim wording from the response “Phase Two:” Source location Response from Ofcom
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 Submit the illegal-harms Codes of Practice to the Secretary of State and progress them through the statutory approval process.
Verbatim wording from the response “The Online Safety Act requires Ofcom to submit our Codes of Practice on illegal harms to the Secretary of State and to publish associated guidance within 18 months of Royal Assent. Once we issue our statement, services will have three months to undertake their illegal content risk assessments. At this point we will also submit the Codes of Practice to the Secretary of State, which, subject to their approval, are to be laid in Parliament for 40 days.” Source location Response from Ofcom
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 Publish and consult on illegal-harms risk guidance, risk profiles, draft Codes of Practice and illegal-content judgements guidance.
Verbatim wording from the response “Phase One: The first step in this was the publication of the Consultation: Protecting people from illegal harms online (‘illegal harms consultation’) on 9 November 2023. As part of this consultation, we published proposals for Codes of Practice which set out how services can comply with their illegal content duties in the Act.⁵ We also published draft Illegal Content Judgements Guidance on how services can identify illegal suicide and illegal self-harm content.” Source location Response from Ofcom
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 Ofcom cannot enforce regulated services’ new duties until required consultations, Codes of Practice, parliamentary approval and other implementation steps are completed.
Verbatim wording from the response “Although the Act is now law, there are numerous procedural steps needed for the new regime to be fully implemented, and these steps need to be completed before services’ legal duties under the regime – and Ofcom’s ability to enforce those duties – come into force. These steps include, for example, the completion of public consultations (the first is currently open for illegal harms); services understanding and managing the risks of harm to their users; and Parliament approving Ofcom’s final Codes of Practices. We explain our plans to implement the regime below.” Source location Response from Ofcom
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 Responsibility for substance supply or marketing falls within Ofcom’s remit only where the activity is covered by Online Safety Act content or activity duties.
Verbatim wording from the response “Ofcom would only have a role in connection with the prevention of supply or marketing of particular substances within the UK insofar as this relates to a type of content or activity that would be caught under duties in the Online Safety Act. Based on the information available in the report, it is not clear that material relating specifically to the supply or marketing of the substance itself would fall in scope of the duties under the Act.” Source location Response from Ofcom
Open published response
25 Oct 2023 Bronwen Grace MORGAN (BM) · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1 Failure to restrict vulnerable individuals' access to self-harm and suicide-facilitating websites View source
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
Bronwen Grace MORGAN (BM) · 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
Bronwen Morgan, who was under the care of local mental health services, travelled to a hotel on 27 August 2020 and was later found there by emergency services. She was conveyed to hospital, where she died from the toxic consequences of a substance after resuscitation attempts failed. The principal concern was that an online forum and potentially similar sites enabled vulnerable people to discuss, obtain information about, and acquire means for self-harm or 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. The report was sent to Ofcom; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict vulnerable individuals' access to self-harm and suicide-facilitating websites
Wider context from the report “The evidence revealed that as from at least February 2020, BM had registered with, & was engaging in discussion forums ████████ This website was mentioned in an earlier PFD Report dated 3.12.19 (copy annexed).
The engagement that BM had with the website encompassed her discussing & seeking advice from fellow users in respect of, methods of self-harm/suicide including the purchasing & use of the substance ████████. This was the substance used by BM which led to her death.
The concern here is that this site & potentially similar self-harm & suicide “facilitating or promoting” sites are accessible/available to those, such as BM who are vulnerable, due to their diagnosed, or otherwise mental illness & provided with an outlet/forum to source & acquire information that potentially equips them with the knowledge & means to either complete suicide, or place them in grave/greater danger of doing so.
I believe that consideration ought to be given to the impact such access/availability has upon those vulnerable individuals researching/contemplating acts of self-harm & whether, & what action(s) may be taken to remove/limit/mitigate/educate such access/availability.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations