PFD report

Miranda Emilia Avanzi · Prevention of Future Deaths report

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Issued 14 Nov 2024•Inner North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
17

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Ready availability of information providing instructions for ending one’s own life
    Part of recurring concern: Inadequate controls on access to online suicide-promoting content
  2. Lack of useful age verification on websites providing suicide guides
    Part of recurring concern: Inadequate controls on access to online suicide-promoting content
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. Action

    Produce the Illegal Harms Register of Risks, risk profiles and risk-assessment guidance for regulated services.

    Stated by OfcomStated completedThe respondent said that this action was complete when they made their response on 14 November 2024.
  2. Action

    Publish Illegal Content Judgements Guidance explaining how services can identify illegal suicide content.

    Stated by OfcomStated completedThe respondent said that this action was complete when they made their response on 14 November 2024.
  3. Action

    Publish the final Illegal Harms Statement, including the Illegal Harms Codes of Practice and guidance.

    Stated by OfcomStated completedThe respondent said that this action was complete when they made their response on 14 November 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Ofcom cannot yet enforce the new online-safety duties because required implementation steps and Parliamentary approval remain outstanding.

    Stated by OfcomUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Inadequate controls on access to online suicide-promoting content.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Inadequate controls on access to online suicide-promoting content.

Open source report

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

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
Page 4 · response
Published 14 November 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

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
Page 5 · response
Published 14 November 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

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
Page 4 · response
Published 14 November 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

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
Page 3 · response
Published 14 November 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Implement the Online Safety Act with Ofcom to regulate illegal and harmful suicide and self-harm content online.

Verbatim wording from the response

“As you may know, the ‘Act’ is a regulatory framework which gained Royal Assent in October 2023, and the government has since been working with Ofcom, the independent regulator, to implement it as quickly and effectively as possible. The Act tackles illegal and legal forms of online suicide content in a number of ways.”

Source location

Response from DSIT
Page 1 · response
Published 14 November 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Introduce a communications offence covering intentional encouragement or assistance of serious self-harm.

Verbatim wording from the response

“We expect the illegal content duties to be fully in effect from Spring 2025. The Act also introduced a new communications offence of encouraging or assisting serious self-harm. This criminalises relevant acts capable of intentionally encouraging or assisting serious self-harm of another person, and was commenced on 31 January 2024.”

Source location

Response from DSIT
Page 1 · response
Published 14 November 2024

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Ofcom cannot 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
Page 3 · response
Published 14 November 2024

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

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
Page 2 · response
Published 14 November 2024

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

The Act does not restrict adults’ access to legal suicide content, limiting protection available through that legislation.

Verbatim wording from the response

“As you highlight in your report, users are able to access harmful suicide content via search engines. Under the Act, search services have targeted duties which require them to minimise the risk of all users encountering illegal content, including illegal suicide and self-harm content. In practice, this could look like removing results for sites that are known to host illegal suicide and self-harm content. Search services must also take or use, where proportionate, user support measures which might for example, signpost users towards sources of support. You state in your letter that you have already seen a source of support being offered by a search engine and that this indicates that the content being viewed is harmful. Whilst the Act does not restrict adult users’ access to legal content, as noted above, search services must provide children with additional protections from PPC.”

Source location

Response from DSIT
Page 2 · response
Published 14 November 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.11

  1. 1

    Submit the Children’s Safety Codes to the Secretary of State for approval and parliamentary laying.

    Stated by OfcomStated plannedThe respondent said that this action was planned when they made their response on 14 November 2024.
  2. 2

    Publish the Researcher Access report and Media Literacy statement.

    Stated by OfcomStated plannedThe respondent said that this action was planned when they made their response on 14 November 2024.
  3. 3

    Issue final guidance for super complaints.

    Stated by OfcomStated plannedThe respondent said that this action was planned when they made their response on 14 November 2024.
  4. 4

    Issue final guidance on transparency reporting for categorised services.

    Stated by OfcomStated plannedThe respondent said that this action was planned when they made their response on 14 November 2024.
  5. 5

    Continue engaging expert stakeholders and commissioning research to develop expertise and evidence on suicide-related online harms.

    Stated by OfcomStated in progressThe respondent said that this action was in progress when they made their response on 14 November 2024.
  6. 6

    Issue draft and final transparency notices to categorised services.

    Stated by OfcomStated plannedThe respondent said that this action was planned when they made their response on 14 November 2024.
  7. 7

    Publish the register of categorised services.

    Stated by OfcomStated plannedThe respondent said that this action was planned when they made their response on 14 November 2024.
  8. 8

    Publish a consultation on additional duties for categorised services.

    Stated by OfcomStated plannedThe respondent said that this action was planned when they made their response on 14 November 2024.
  9. 9

    Publish the Protection of Children Statement setting out the final position on children’s risk assessments and safety measures.

    Stated by OfcomStated plannedThe respondent said that this action was planned when they made their response on 14 November 2024.
  10. 10

    Issue final guidance on age assurance for pornography providers.

    Stated by OfcomStated plannedThe respondent said that this action was planned when they made their response on 14 November 2024.
  11. 11

    Publish the final Children’s Access Assessments Guidance.

    Stated by OfcomStated plannedThe respondent said that this action was planned when they made their response on 14 November 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Decisions on prosecuting suspected encouragement or assistance of suicide rest with the Crown Prosecution Service after police investigation.

    Stated by Department for Science, Innovation and TechnologyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 Children’s Safety Codes to the Secretary of State for approval and parliamentary laying.

Verbatim wording from the response

“Providers of services that are likely to be accessed by children will then have three months to carry out children’s risk assessments. At this point we will also submit the Children’s Safety Codes to the Secretary of State, which, subject to approval, are to be laid in Parliament for 40 days.”

Source location

Response from OFCOM
Page 7 · response
Published 14 November 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Publish the Researcher Access report and Media Literacy statement.

Verbatim wording from the response

“Phase 3: Duties on categorised services, incl. transparency Q1 2025: Ofcom issues final guidance on transparency reporting. Q4 2025: Ofcom publishes register of categorised services. Q1–Q3 2025: Ofcom publishes Researcher Access report. Q2–Q3 2025: Ofcom publishes Media Literacy statement. Q3–Q4 2025: Ofcom issues draft and final transparency notices to categorised services. Q4 2025 to Q1 2026: First transparency reports begin published by categorised services. Q4 2025 to Q1 2026: Ofcom publishes consultation on additional duties on categorised services.”

Source location

Response from OFCOM
Page 11 · response
Published 14 November 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Issue final guidance for super complaints.

Verbatim wording from the response

“Fees and super complaints October 2024: Consultation on fees. April 2025: Ofcom issues advice to SoS on fee thresholds. Q4 2025–Q1 2026: Ofcom issues final guidance for super complaints.”

Source location

Response from OFCOM
Page 11 · response
Published 14 November 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Issue final guidance on transparency reporting for categorised services.

Verbatim wording from the response

“Phase 3: Duties on categorised services, incl. transparency Q1 2025: Ofcom issues final guidance on transparency reporting. Q4 2025: Ofcom publishes register of categorised services. Q1–Q3 2025: Ofcom publishes Researcher Access report. Q2–Q3 2025: Ofcom publishes Media Literacy statement. Q3–Q4 2025: Ofcom issues draft and final transparency notices to categorised services. Q4 2025 to Q1 2026: First transparency reports begin published by categorised services. Q4 2025 to Q1 2026: Ofcom publishes consultation on additional duties on categorised services.”

Source location

Response from OFCOM
Page 11 · response
Published 14 November 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Continue engaging expert stakeholders and commissioning research to develop expertise and evidence on suicide-related online harms.

Verbatim wording from the response

“As part of our preparatory work for implementation, we have been actively engaging with a range of expert stakeholders including government, law enforcement, and charities such as the Samaritans to develop our understanding, expertise and evidence base in relation to suicide, and to ensure that we are aware of developing areas of risk. We have also been concentrating on growing our internal”

Source location

Response from OFCOM
Page 3 · response
Published 14 November 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Issue draft and final transparency notices to categorised services.

Verbatim wording from the response

“Phase 3: Duties on categorised services, incl. transparency Q1 2025: Ofcom issues final guidance on transparency reporting. Q4 2025: Ofcom publishes register of categorised services. Q1–Q3 2025: Ofcom publishes Researcher Access report. Q2–Q3 2025: Ofcom publishes Media Literacy statement. Q3–Q4 2025: Ofcom issues draft and final transparency notices to categorised services. Q4 2025 to Q1 2026: First transparency reports begin published by categorised services. Q4 2025 to Q1 2026: Ofcom publishes consultation on additional duties on categorised services.”

Source location

Response from OFCOM
Page 11 · response
Published 14 November 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Publish the register of categorised services.

Verbatim wording from the response

“Phase 3: Duties on categorised services, incl. transparency Q1 2025: Ofcom issues final guidance on transparency reporting. Q4 2025: Ofcom publishes register of categorised services. Q1–Q3 2025: Ofcom publishes Researcher Access report. Q2–Q3 2025: Ofcom publishes Media Literacy statement. Q3–Q4 2025: Ofcom issues draft and final transparency notices to categorised services. Q4 2025 to Q1 2026: First transparency reports begin published by categorised services. Q4 2025 to Q1 2026: Ofcom publishes consultation on additional duties on categorised services.”

Source location

Response from OFCOM
Page 11 · response
Published 14 November 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Publish a consultation on additional duties for categorised services.

Verbatim wording from the response

“Phase 3: Duties on categorised services, incl. transparency Q1 2025: Ofcom issues final guidance on transparency reporting. Q4 2025: Ofcom publishes register of categorised services. Q1–Q3 2025: Ofcom publishes Researcher Access report. Q2–Q3 2025: Ofcom publishes Media Literacy statement. Q3–Q4 2025: Ofcom issues draft and final transparency notices to categorised services. Q4 2025 to Q1 2026: First transparency reports begin published by categorised services. Q4 2025 to Q1 2026: Ofcom publishes consultation on additional duties on categorised services.”

Source location

Response from OFCOM
Page 11 · response
Published 14 November 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Publish the Protection of Children Statement setting out the final position on children’s risk assessments and safety measures.

Verbatim wording from the response

“Services that are likely to be accessed by children will have additional duties to protect children’s online safety. As set out above, we published our consultation on Protecting children from harms online (‘Protection of Children Consultation’) on 8 May 2024 and our statement will be published in April 2025.”

Source location

Response from OFCOM
Page 6 · response
Published 14 November 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Issue final guidance on age assurance for pornography providers.

Verbatim wording from the response

“Phase 2: Child safety duties and pornography January 2025: Ofcom issues Children’s Access Assessment Guidance. April 2025: Ofcom draft codes for protection of children from child sexual abuse and exploitation; submits to Ofcom for approval. June 2025: Parliament approves protection of children codes. January 2025: Ofcom issues final guidance on age assurance for pornography providers. July 2025: Codes come into force. Relevant services must comply with the child safety duties and Ofcom can enforce against non-compliance. January–April 2025: Services complete children’s access assessment. April–July 2025: Consultation on protection of children.”

Source location

Response from OFCOM
Page 11 · response
Published 14 November 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Publish the final Children’s Access Assessments Guidance.

Verbatim wording from the response

“All user-to-user and search services are required to carry out children’s access assessments. A children’s access assessment is a process for establishing whether a service is ‘likely to be accessed by children’ within the meaning of the Act. We intend to publish our final Children’s Access Assessments Guidance in January 2025. Regulated services will then have three months to complete children’s access assessments. If they conclude that their service is likely to be accessed by children, they will need to carry out a children’s risk assessment and comply with the children’s safety duties in the Act.”

Source location

Response from OFCOM
Page 6 · response
Published 14 November 2024

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Decisions on prosecuting suspected encouragement or assistance of suicide rest with the Crown Prosecution Service after police investigation.

Verbatim wording from the response

“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 DSIT
Page 1 · response
Published 14 November 2024

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026