Deborah Jane Cooper · Prevention of Future Deaths report

On 27 February 2024 I opened the Inquest into the death of Deborah Jane Cooper (Aged 61) whose body was found at her home in Melksham on 21 February 2024. The results of the post mortem examination carried out on Deborah showed (subject to inquest) that she died from ████████ Toxicity.

Found at the scene of her death was apparatus that appears to have been constructed by Deborah, the sole purpose of which was to produce ████████ which appears to have directly resulted in her death. There were notes left at the scene as regards her intention to end her life. As you will be aware from my earlier amended Regulation 28 Report dated 25 April 2024 (copy attached) in which I added your predecessor as a recipient, it would appear that Deborah had downloaded a publication from the internet called ████████ which is jointly written by ████████ and ████████ My investigations are ongoing as to how she acquired that digital copy. The book as previously indicated provides clear instructions as to how to make the piece of apparatus which appears to have been put together by Deborah and which has resulted in her ending her life.

I stated in my original report that separately I had discovered that the same publication was available directly from Amazon UK via their website. As you will be aware the law states that a Coroner has a duty to make a report, such as this report, with a view to the prevention of future deaths where as part of an investigation, evidence raises such a concern. I indicated earlier in my first Regulation 28 Report that I felt that duty had arisen in this case when I discovered the same publication that I believe was used by Deborah to provide instructions as to how to put a ████████ generator together with a view to ending her life, that such a book is also freely available on the open market on Amazon.co.uk website and supplied directly by Amazon UK. I was concerned that the marketing and supply of such a book giving such clear instructions and advice as regards different methods for an individual to end one's life is of the utmost concern as is the regulation as regards the supply of such publications whose sole purpose is to provide information to those contemplating on ending their lives. I acknowledge that I have taken the unusual step here of issuing a second Regulation 28 Report to you, but this has come about as a result of fresh evidence coming into my possession which in my view triggers my duty in law to make a second report identifying a further concern.

I would refer you to the response to my first Regulation 28 Report from the then Parliamentary Under Secretary of State at The Department of Science, Innovation and Technology, ████████ dated 20 June 2024 where he highlighted the possible offence under the Suicide Act 1961 and also pointed me in the direction of the regulatory framework of the Online Safety Act 2023.

Having conducted my own research in the matter I wrote to the Chief Executive of Ofcom seeking clarity as regards the scope of the online safety legislation. I enclose with this Regulation 28 a copy of ████████ Chief Executive of Ofcom’s, response dated 16 July 2024.

There are 2 issues that are of concern to me both of which leave me with the concern that there appears to be nothing in the legislative arsenal to substantively dissuade Amazon UK from marketing this publication to members of the public and children, if supplied direct from their warehouse. Those concerns are based on :-

a. whilst there may be an offence under the Suicide Act 1961 as amended by the Coroners’ and Justice Act 2009 to include a limited company the penalty for such an offence was not changed and it remains as imprisonment, and you cannot imprison a limited company;

b. Having regard to the response from Ofcom (copy attached for ease of reference), they have made it clear in paragraph 4 that where “Amazon UK itself directly offers a product for sale via its own marketplace, that will be provider content (which is not in scope of the OSA) ….. I have additionally enclosed with this letter a copy taken today from the Amazon website which clearly shows that Amazon UK are directly offering this particular book for sale via its own marketplace.

There therefore seems to be a significant gap in the legislation to stop material like this being directly marketed by an organisation, in this case by Amazon UK, utilising its own marketplace. I fully acknowledge that if Amazon were marketing this on behalf of a third party seller, then that would be covered by the online safety legislation but that does not appear to be the case here and this book is being provided directly by the Amazon UK Warehouse.

I have additionally enclosed a copy of the response that I received to my Regulation 28 Report from Amazon UK. I should point out here that I have been 1 of 4 coroners who have written to Amazon about this issue.

As previously stated it is not for a Coroner to make recommendations and I hope that you will not take offence that I have raised this issue again with your department, the sole purpose of which is to prevent future deaths and in doing so highlighting what I perceive to be a gap in the legislation in respect of which it is of course for His Majesty’s Government to consider how best to address the concern, if you accept the concern raised in this letter.