Deborah Cooper

PFD Report All Responded Ref: 2024-0199
Date of Report 26 February 2024
Coroner David Ridley
Response Deadline est. 24 June 2024
All 2 responses received · Deadline: 24 Jun 2024
Response Status
Responses 2 of 4
56-Day Deadline 24 Jun 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
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 whereas part of an investigation evidence raises such a concern. That duty in my view has arisen in this case when I discovered that books giving clear instructions as to how an individual might want to end his or her life was freely available on the open market on the Amazon.co.uk website. I am 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 his or her life at their own hands 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 have identified 2 publication that give such advice and there may be more currently being marketed on the Amazon.co.uk website.

I have raised the concern and ask that both Amazon.co.uk and His Majesty’s Government consider how best to address the concern raised in this letter. It is not for a Coroner to make recommendations and the limit of my coronial power is limited to airing the concern in the first place.
Responses
Amazon
15 Apr 2024
Amazon reviewed the two books in question against their content guidelines but decided not to remove them, citing a commitment to freedom of expression. They noted that a banner is displayed on sensitive product pages to provide access to Samaritans' advice. AI summary
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Dear Sir/Madam We refer to the Regulation 28 Report to Prevent Future Deaths (“Report”) dated 26 February 2024 (received 28 February 2024). The Report references two books available on Amazon.co.uk:

(together, the “Books” and each a “Book”). We offer our deepest sympathies to the family and friends of Mrs Cooper. We have carefully considered the contents of the Report. As a bookseller, we believe that providing access to written speech and a variety of viewpoints is important, including books that some may find objectionable. We have content guidelines governing which books can be listed for sale and promptly investigate when a concern is raised. We have reviewed each Book against our content guidelines, taking account of your comments, and have decided not to remove either of them from sale. We recognise that there are heavily debated titles in our store and different views on where to draw the line protecting freedom of expression. We carefully consider the types of content we make available and think broad guidelines to protect freedom of expression, including controversial content, serve readers better than censorship. We strive to offer a broad selection for customers, even if we don't agree with the message or sentiment of the book itself. At the same time, we are committed to taking measures not to surprise customers with potentially controversial or sensitive content. We display a banner on the product detail page of titles like those

referenced in the Report, which presents customers with information on how to access free and confidential advice from the Samaritans.
Department for Business and Trade
28 Jun 2024
The Department for Business and Trade noted the concerns but stated they cannot commit to actions during the pre-election period. They clarified that existing consumer protection law has limited scope, and more directly relevant legislation falls outside their department's remit. AI summary
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Dear Mr Ridley,

I would like to begin by expressing my deepest condolences to the family and friends of Deborah Jane Cooper following her death and the circumstances that surrounded it. I recognise the gravity of the concerns raised in your Report and I am grateful for the opportunity to respond to this Report to Prevent Future Deaths. As we are in a pre-election period, I apologise that I cannot comment on or commit to further actions to prevent future deaths as these will be for the new Government.

The Department for Business and Trade is, inter alia, responsible for consumer protection law, including the Consumer Protection from Unfair Trading Regulations 2008 (“CPRs”), which is shortly to be updated by Part 4, Chapter 1 of the Digital Markets, Competition and Consumers Act 2024 (DMCC Act). The DMCC Act received Royal Assent in May 2024.

There is limited scope to address the issues raised in your Report through existing consumer protection legislation. For example, while the scope of the protection offered to consumers by the unfair trading legislation (referred to above) is broad, its focus is primarily to protect consumer’s economic interests. This legislation does not impose a blanket ban on the sale of the particular products in issue.

However, there is legislation, which falls outside of the scope of my Department’s responsibilities, which is more directly relevant including section 2(1) of the Suicide Act 1961 (as amended), which makes it an offence for a person to commit 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. It is a matter for the Police and Crown Prosecution Service to consider and, where appropriate, pursue prosecutions.

In addition, the new Online Safety Act requires all in-scope services, including in-scope marketplaces, to rapidly remove regulated content, including suicide content, where they have reasonable grounds to consider that it crosses the criminal threshold. I understand that

a letter has been issued in response to your Report from the Department for Science, Innovation and Technology (DSIT) regarding the scope of the Online Safety Act in relation to these issues. Ofcom is the independent regulator for the Online Safety Act and is working with the DSIT to implement the Act which received Royal Assent in October.
Report Sections
Investigation and Inquest
Today (22nd February 2024), I received notification from Wiltshire Police as regards the sudden death of Deborah Jane Cooper whose body was found at her home in Melksham yesterday on the 21st February 2024. Deborah was aged 61 at the time of her death. I have commenced as of today’s date a Coronial Investigation into Deborah’s death and will shortly be opening an Inquest into her death once the postmortem examination has taken place, and I am in a position to release her body back to the family.
Circumstances of the Death
From information provided by the police I have reason to suspect that her death is unnatural and given the cherry red complexion noted in relation to photographs that I have seen of Deborah’s body and the presence of apparatus, some of which was purchased on line from Amazon, it appears that she has put together an apparatus t died from carbon monoxide poisoning. Notes were left at the scene as regards her intention to end her life.

As part of the police report I received photographs taken from her computer of a publication . My investigation will establish how she acquired that digital copy. The book essentially contains instructions on how to make a piece of apparatus

The book also covers other methods again with the aim of end an individual’s life.

I then Googled the said publication in order to see if the publication could be purchased here in the UK, which then led me to the Amazon UK site where I found that copies of this publication were freely available and supplied direct by Amazon UK. N

there was also a similar publication

“was also marketed in both electronic and paperback formats. This second publication seems to also suggest that it may contain instructions as to how one goes about ending one’s life.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.