Bronwen Grace MORGAN (BM) · Prevention of Future Deaths report

On 10 September 2020 I commenced an investigation into the death of Bronwen Grace MORGAN (BM) . The investigation concluded at the end of the inquest 20/10/2023.

The conclusion of the inquest was Suicide.

1a ████████ Toxicity
1b
1c
II

Bronwen Morgan had a diagnosis of Emotionally Unstable Personality Disorder. This manifested itself in fluctuating symptoms including acute periods of distress and anxiety leading to acts of deliberate self-harm. She was under the care and treatment of local mental health services. She was engaging in dialectical behaviour therapy that indicated treatment for Emotionally Unstable Personality Disorder. On 27.8.20 she has travelled to a ████████
████████
She was located in the hotel by the emergency services and conveyed to the University Hospital of Wales, Heath. Despite resuscitation attempts she did not regain consciousness and died from the toxic consequences of the substance. Material located on her mobile phone and at the scene demonstrated that she likely intended the consequences of her deliberate actions to be her own death.

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.