Guy Scotchford

PFD Report All Responded Ref: 2024-0047
Date of Report 31 January 2024
Coroner Emma Hillson
Response Deadline est. 27 March 2024
All 2 responses received · Deadline: 27 Mar 2024
Response Status
Responses 2 of 3
56-Day Deadline 27 Mar 2024
All responses received
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Coroner’s Concerns
It was clear from the evidence of the investigating officer that the website ( is still active and from this website a " can be downloaded. This document gives a direct link to a company from which can be purchased in the UK and home delivered. The police investigation determined that this named company did receive and supply that order. The downloaded document provides step by step instruction on how to end your life with specific advice and direction on the use of certain equipment.

The investigating officer made a recent internet search of this website which states that it provides practical DIY information to enable readers to take control over their own life and death. This website is available to anyone to access online.
Responses
National Crime Agency
25 Mar 2024
The NCA has been engaging with Ofcom to scope out how they can work together to combat online suicide content and reduce access to harmful materials. They also highlighted broader government efforts through the Online Safety Act and the Criminal Justice Bill to address such content and drug supply. AI summary
View full response
Dear Ms Hilson, Thank you for your letter of 1 February 2024 in relation to the death of Guy Douglas Scotchford. I would like to say how deeply saddened I was to read about the circumstances of Mr Scotchford’s death. I would like to offer my condolences to his family and loved ones. Thank you for bringing to my attention your concerns regarding the availability of inert gasses and information regarding suicide methods online. The NCA recognises that the sale of nitrogen and other inert gasses is not in itself prohibited due to their many uses, primarily in industry, which include within hydraulic systems, cooling applications, creation of various beverages, and food packaging. The Health and Safety Executive sets out and enforces regulations in respect of the safety standards of gas canisters but this does not extend to who can purchase the canisters. As a result of your letter we have been engaging with Ofcom, the online safety regulator under the Online Safety Act 2023, to scope out how we can work effectively together, within our respective roles, to combat suicide content online. The NCA understands that Ofcom is in the process of consulting on its draft codes of practice and guidance that will explain the steps that regulated online services will need to take to meet their legal duties under the Act to protect their users in the UK from this sort of content. The NCA also welcomes the government’s commitment to reducing the lives lost to suicide set out in the Suicide Prevention strategy, published on 11

OFFICIAL OFFICIAL

Leading the UK's fight to cut serious and organised crime 2 of 3

September 2023 by the Department of Health and Social Care, The strategy sets out national ambitions for suicide prevention over the next 5 years, and includes a wide range of individuals and organisations having a role to play in suicide prevention. As a consequence of the strategy, all areas of the country now have local suicide prevention plans, including guidance on providing bespoke support to specific groups and communities of concern, including those who have been in contact with mental health services. I understand this is supported by a £57 million investment through the NHS Long Term Plan. Within the strategy, the NCA particularly welcomes the references to continuing to support search engine and social media platforms to remove content that encourages suicide and provide ready access to suicide prevention services, and the read across to the Online Safety Act 2023. The strategy also aims to clearly define who is responsible and accountable for keeping the public safe from this content. Work so far has involved high quality signposting and support being prevalent across a wide range of platforms. A recent example of the latter is the Google OneBox, a pop-up alert that provides details about how to contact Shout, a mental health support service, or the Samaritans. The strategy foreshadows the recently enacted Online Safety Act 2023, which you will no doubt be familiar with. This Act requires all in-scope companies to tackle illegal content, such as suicide and self-harm content. Requirements have also been made that the largest services will have to offer adults optional tools to limit their exposure to legal content that encourages, promotes or provides instructions for suicide or self-harm. A further extension of this is the Criminal Justice Bill, introduced to the House of Commons on 14 November 2023, and, at the time of writing, is in its reporting stage at the House of Commons. Sections 11 and 12 of this bill look to replace Section 184 of the Online Safety Act 2023 with a broader offence covering “any act capable of encouraging or assisting serious self-harm of another person”, with an emphasis on harmful intent. The handbook in question also describes a number of drugs that may be used for suicide purposes and which are classified as Class A and Class B under schedules 2 and 3 of the Misuse of Drugs Act 1971. These are being tackled under the HMG Drugs Strategy, by prioritising breaking drug supply chains and limiting the volume of illicit drugs available in the UK. I also wanted to bring to your attention the work that the Department of Health and Social Care are doing with the Samaritans on the delivery of their online excellence programme. This involves developing a hub of excellence in suicide prevention and the online environment, working in partnership with

OFFICIAL OFFICIAL

Leading the UK's fight to cut serious and organised crime 3 of 3

Facebook, Instagram, Google, YouTube, Twitter and Pinterest and aims to promote consistently high standards across the sector. This will be crucial in changing the availability of harmful content online. Thank you for bringing your concerns to our attention. I hope you find this summary of the work being done across the government and the NCA, helpful. If I can be of any further assistance please do not hesitate to contact me.

T/Deputy Director Borders & Commodities National Crime Agency
Department for Science Innovation Technology
4 Sep 2025
DSIT highlights the Online Safety Act as laying the foundation for strong protections against illegal online content. DSIT officials will raise concerns regarding inert gases with the DHSC's Concerning Methods Working Group to suggest engaging with UK sellers to minimise harm. AI summary
View full response
Dear Ms Hillson, 

I want to thank you for the opportunity to respond to this Report to Prevent Future Deaths, regarding the death of Guy Douglas Scotchford. I was deeply saddened to read about the circumstances surrounding Guy's tragic death and would like to extend my deepest condolences to his family and friends for their loss.   

As the Secretary of State for Science, Innovation and Technology, I am responsible for the Online Safety Act (the ‘Act’) which received Royal Assent in 2023. The Act lays the foundation for strong protections against illegal content for all users and harmful material for children. The government is committed to working with Ofcom, the independent regulator, to ensure the Act is implemented quickly and effectively. The new laws apply to search services and all companies that allow users to post content online or to interact with each other (referred to as user-to-user services in the Act). This includes a broad range of websites, apps and other services, including social media services, consumer cloud storage sites, video sharing platforms, online forums, dating services, online instant messaging services and online marketplaces where they allow (regulated) user-generated content, for example images or content descriptions uploaded by users.   

Under the Act, all in-scope services, regardless of their size, must have proportionate systems and processes to prevent all users from encountering priority illegal content. Under the Act, intentionally encouraging suicide and certain drug-related offences are priority offences and content that amounts to those offences is deemed ‘priority illegal content’. Priority offences reflect the most serious and prevalent illegal content and activity, against which companies must take proactive measures, as well as ensuring their services are not used to facilitate or commit a priority offence. These duties came into effect in March 2025, and within the first month Ofcom had already launched several enforcement programmes against companies failing to comply with these duties, including a pro-suicide forum. On 1 July, this forum decided to voluntarily restrict access to UK users due to the legal risks associated with its duties under the Act. The Act also introduced a new communications offence of intentionally encouraging or assisting serious self-harm, which was commenced on 31 January 2024.  

Regulated suicide content is illegal under the Online Safety Act where it amounts to an offence under the Suicide Act 1961 (which is the responsibility of the Ministry of Justice). Under section 2(1) of the Suicide Act 1961 (as amended by section 59 of the Coroners and Justice Act 2009) 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 person committing the offence need not know the other person or even be able to identify them. An offence may be committed whether or not a suicide or attempted suicide takes place.  

Under the Interpretation Act 1978 a "person" committing an offence "includes a body of persons corporate or unincorporate" unless the relevant provision says or implies otherwise. As with other offences, the offence under section 2(1) of the Suicide Act is capable of being committed by a company though. However, simply making available, or facilitating the provision of, resources which provide information detailing methods of suicide, where there is no intention to encourage or assist suicide, is not an offence under the Suicide Act. 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. The CPS policy on assisted suicide1 sets out the factors which prosecutors in England and Wales will consider, in addition to those already outlined in the Code for Crown Prosecutors, when deciding whether it is in the public interest to prosecute in cases of encouraging or assisting suicide.  

The strongest protections in the Online Safety Act are for children, and the legislation provides them with additional protections from harmful content which does not reach the criminal threshold. Under the Act, where a user-to-user service is likely to be accessed by children, they must put in place measures to prevent children of all ages from encountering legal content that encourages, promotes or provides instructions for suicide or self-harm. The measures must include the use of age assurance. These duties came into effect on 25 July. 

We know that users may find online suicide content via search services. Under the Act, search services have targeted duties that focus on minimising the risk of all users encountering illegal suicide and self- harm search content, and children from encountering legal content which encourages or provide instructions for suicide or self-harm. In practice, this could look like removing results for sites that are known to host illegal suicide and self-harm content. These duties also include a requirement to take or use, where proportionate, user support measures, for example, signposting users towards sources of support. Combined, these duties are expected to play a key role in reducing the volume of user traffic directed to websites with illegal suicide and self-harm content, reducing the ease with which users can find these kinds of sites and content. 

In your report, you raise concern that ‘ ’ is still available online to members of the public. I would firstly like to clarify that under the child safety duties, regulated search services must minimise the risk of children encountering (in search results or directly by clicking on them) content which encourages or provides instructions for suicide or self-harm, even where it is legal. This would involve such content on an online marketplace, and if such search results included content – related to a book – which itself encouraged or provided instructions for suicide, or a search result led directly to a digital copy of a book which did so, the risk of children encountering this content would have to be minimised by the search service.  

As previously explained, the Online Safety Act does not prevent adult users from accessing legal suicide and self-harm content. In some cases, such content may be trying to provide support to those in need and this is therefore a complicated area to regulate. To be clear, I am not saying that ‘ ’ is such a book. 

The issue therefore is whether the authors or distributors of ‘ or similar books are committing an offence. However, the enforcement of existing offences is not for the government, but for the police and the Crown Prosecution Service and it is ultimately for the courts to decide if an offence has been committed. As you are aware, relevant criminal offences have a high threshold to avoid criminalising people who are expressing suicidal feelings and those offering them

support, by for example, sharing their own experiences.  As noted above, offences under the Suicide Act 1961 and their thresholds are under the remit of the Ministry of Justice. 

The government is committed to delivering a renewed drive to tackle the number of lives lost to suicide. Cross-government action is key in achieving this, and coordinated action is taking place across government to enable us to rapidly identify and proactively tackle emerging methods of suicide as quickly and effectively as possible, with a series of interventions to reduce access and awareness of dangerous methods.  

As leaders of the Suicide Prevention Strategy, officials from the Department for Health & Social Care (DHSC) lead a Concerning Methods Working Group to raise awareness of and tackle access to emerging methods of suicide. Deaths using nitrogen are monitored routinely as part of this. The working group involves representatives from the voluntary community and social enterprise sector, police, academics and the NHS, as well as government departments including Department of Science, Innovation and Technology. DSIT officials will raise the concerns in your letter around Nitrogen with this group and suggest that engagement with UK sellers is undertaken to raise awareness of and minimise the risk of harm to individuals.   

I would like to thank you again for drawing this to my attention and I hope that this response is useful in setting out where the Online Safety Act will offer significant new protections against illegal content for all users. The government will continue to keep online safety policy under review and identify areas where we can build on the Act, so it is important for me to be made aware of online safety related Reports to Prevent Future Deaths.
Report Sections
Investigation and Inquest
On 7th July 2023, I commenced an investigation into the death of Guy Douglas Scotchford. The investigation concluded at the end of the inquest on 30th January 2024.

I recorded the cause of death as

1a) Asphyxiation

My conclusion as to the death was as follows:

Suicide Information Classification: CONTROLLED Information Classification: CONTROLLED
Circumstances of the Death
Guy Scotchford had a long history of mental health problems with chronic suicidal ideation and believed he was suffering from a condition called Mast Cell Activation Syndrome, something he had researched extensively. This impacted on his day-to-day health and well being. He had a complex past medical history to include depression, addiction and chronic multi system, medically unexplained symptoms of unclear cause. There had not been a formal diagnosis of Mast Cell Activation Syndrome as there was minimal evidence to reach this but he was under specialist care provided by the Clinical Immunology Department at Derriford Hospital who were providing valuable advice and guidance to manage his symptoms. Guy had previously disclosed to his sister, GP and Mental Health Services that he had researched ways to end his life and at one stage stated he had a plan in place but that he did not intend to act on those plans. He had some contact with mental health services and engaged in 3 intervention sessions with Wellbeing Coaches in October 2022 following which he reported feeling better. His final contact with the Mental Health Connect team was on 15th May 2023 when he reported ongoing chronic suicidal ideation. He agreed to contact with his GP and a safety plan was discussed. A review was held with his GP on 31st May 2023 at which time his physical and mental health was discussed at length. There was no change in his chronic suicidal thoughts, and he was keen to explore treatment and support for his condition. He declined any referral for further mental health or psychology services at that time.

Guy contacted his sister on the telephone in the early hours of 1st July 2023 and his opening comment was that he loved her. She stated that she would call him later. On attempting to contact him later that morning she was unable to get a response and raised a concern for welfare. Police officers attended his home address and he was found deceased in the bath. His death was confirmed at 15:24 on 1 July 2023. His death was due to Asphyxiation.

Police Officers at the scene located a printed 60-page document at his home address titled “ ” which had been printed from a website - .

. Police enquiries confirmed that this company received and delivered an order and they also provided a copy invoice dated 28/04/2022. Information Classification: CONTROLLED Information Classification: CONTROLLED
Inquest Conclusion
Suicide Information Classification: CONTROLLED Information Classification: CONTROLLED

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.