Deborah Cooper
PFD Report
All Responded
Ref: 2024-0395
All 1 response received
· Deadline: 12 Sep 2024
Response Status
Responses
1 of 2
56-Day Deadline
12 Sep 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
stated in my original report that separately had discovered that the same publication was available directly Amazon UK via their website. As you will be aware the law states that a Coroner has a 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. indicated earlier in my first Regulation 28 Report that felt that duty had arisen in this case when discovered the same publication that believe was used by Deborah to provide instructions as to how to Igenerator 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. 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_ acknowledge that 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 Wiltshire & Swindon Coroner's Office; 26 Endless Street; Salisbury, Wiltshire; SPI IDP Tel 01722 438900 Fax 01722 332223
61) put from duty put 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 Idated 20 June 2024 where he highlighted the possible offence under the Sulcide Act" 796/ and also pointed me in the direction of the regulatory framework of the Online Safety 2023 . Having conducted my own research in the matter wrote to the Chief Executive of Ofcom seeking clarity as regards the scope of the online safety legislation_ enclose with this Regulation 28 a copy ofl Chief Executive of Ofcom'$, response dated 16 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, 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) have additionally enclosed with this letter a copy image taken 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 me to be a significant gap in the legislation to stop material Iike this being directly marketed by an organisation, in this case by Amazon UK, utilising its own marketplace 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 have additionally enclosed a copy of the response that received to my Regulation 28 Report from Amazon UK should point out here that have been of 4 coroners who have written to Amazon about this issue_ As previously stated is it not for a Coroner to make recommendations and hope that you will not take offence that have raised this issue again with your department;, the sole purpose of which is to prevent future deaths and in doing so highlighting what 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 .
61) put from duty put 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 Idated 20 June 2024 where he highlighted the possible offence under the Sulcide Act" 796/ and also pointed me in the direction of the regulatory framework of the Online Safety 2023 . Having conducted my own research in the matter wrote to the Chief Executive of Ofcom seeking clarity as regards the scope of the online safety legislation_ enclose with this Regulation 28 a copy ofl Chief Executive of Ofcom'$, response dated 16 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, 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) have additionally enclosed with this letter a copy image taken 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 me to be a significant gap in the legislation to stop material Iike this being directly marketed by an organisation, in this case by Amazon UK, utilising its own marketplace 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 have additionally enclosed a copy of the response that received to my Regulation 28 Report from Amazon UK should point out here that have been of 4 coroners who have written to Amazon about this issue_ As previously stated is it not for a Coroner to make recommendations and hope that you will not take offence that have raised this issue again with your department;, the sole purpose of which is to prevent future deaths and in doing so highlighting what 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 .
Responses
The department clarifies that the Online Safety Act protects children from harmful content related to suicide/self-harm but does not prevent adults from accessing legal content. It notes that enforcement of existing offences under the Suicide Act 1961 falls to police and the Crown Prosecution Service, which is under the Ministry of Justice's remit.
AI summary
View full response
Dear Mr Ridley,
Thank you for the opportunity to respond to this second Report to Prevent Future Deaths, regarding the death of Deborah Jane Cooper. I was deeply saddened to read about the circumstances surrounding Deborah’s tragic death and would like to extend my deepest condolences to her family and friends for their loss.
Following your further investigation and the response you received from Ofcom referenced in your letter, I completely understand and appreciate your decision to issue a second Regulation 28 Report. As the Secretary of State responsible for the Online Safety Act and online harms more broadly, I will respond to your further queries as per my department’s remit and having engaged with the Ministry of Justice on the areas which fall into their remit.
In your letter, you raise concern that there appears to be nothing in the Online Safety Act that dissuades Amazon UK from marketing to members of the public, including adults and children. Before separately addressing the two specific issues of concern you raise, I would like to clarify that whilst the Act does not prevent adults from seeking out legal content, under the Child Safety Duties children will be protected from encountering harmful content including that which falls below the criminal threshold on regulated services.
Under the Act, regulated search services must minimise the risk of children encountering (in search results or directly by clicking on them) ‘primary priority 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. The government is working closely with Ofcom to ensure these duties are implemented as quickly and effectively as possible.
Now I will address the two specific issues you raise in your letter, the first of which sets out your concern that a limited company cannot be imprisoned under the Suicide Act 1961 as amended by the Coroners’ and Justice Act 2009. Whilst the Suicide Act 1961 does not itself provide for a penalty other than imprisonment, under section 120 of the Sentencing Act 2020 the Crown Court has a general power to impose a fine on an offender convicted on indictment so there is no legislative gap in terms of sentencing if a company were to be convicted of an offence under the 1961 Act. The Suicide Act 1961 falls within the remit of the Ministry of Justice, should you have any further questions on this.
I will now turn to the second issue you raise, that where Amazon or other providers are selling potentially harmful books related to suicide and self-harm directly, such content is out of scope of the Online Safety Act.
The Online Safety Act does not prevent adult users from accessing legal suicide and self-harm content, regardless of whether it is user generated content or provider 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 set out above, offences under the Suicide Act 1961 and their thresholds are under the remit of the Ministry of Justice.
I would like to thank you again for drawing this to my attention and hope that this response has assisted your investigation. Should you have any further queries or concerns in relation to the relevant offences as set out above, the Ministry of Justice will be best placed to answer these.
Thank you for the opportunity to respond to this second Report to Prevent Future Deaths, regarding the death of Deborah Jane Cooper. I was deeply saddened to read about the circumstances surrounding Deborah’s tragic death and would like to extend my deepest condolences to her family and friends for their loss.
Following your further investigation and the response you received from Ofcom referenced in your letter, I completely understand and appreciate your decision to issue a second Regulation 28 Report. As the Secretary of State responsible for the Online Safety Act and online harms more broadly, I will respond to your further queries as per my department’s remit and having engaged with the Ministry of Justice on the areas which fall into their remit.
In your letter, you raise concern that there appears to be nothing in the Online Safety Act that dissuades Amazon UK from marketing to members of the public, including adults and children. Before separately addressing the two specific issues of concern you raise, I would like to clarify that whilst the Act does not prevent adults from seeking out legal content, under the Child Safety Duties children will be protected from encountering harmful content including that which falls below the criminal threshold on regulated services.
Under the Act, regulated search services must minimise the risk of children encountering (in search results or directly by clicking on them) ‘primary priority 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. The government is working closely with Ofcom to ensure these duties are implemented as quickly and effectively as possible.
Now I will address the two specific issues you raise in your letter, the first of which sets out your concern that a limited company cannot be imprisoned under the Suicide Act 1961 as amended by the Coroners’ and Justice Act 2009. Whilst the Suicide Act 1961 does not itself provide for a penalty other than imprisonment, under section 120 of the Sentencing Act 2020 the Crown Court has a general power to impose a fine on an offender convicted on indictment so there is no legislative gap in terms of sentencing if a company were to be convicted of an offence under the 1961 Act. The Suicide Act 1961 falls within the remit of the Ministry of Justice, should you have any further questions on this.
I will now turn to the second issue you raise, that where Amazon or other providers are selling potentially harmful books related to suicide and self-harm directly, such content is out of scope of the Online Safety Act.
The Online Safety Act does not prevent adult users from accessing legal suicide and self-harm content, regardless of whether it is user generated content or provider 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 set out above, offences under the Suicide Act 1961 and their thresholds are under the remit of the Ministry of Justice.
I would like to thank you again for drawing this to my attention and hope that this response has assisted your investigation. Should you have any further queries or concerns in relation to the relevant offences as set out above, the Ministry of Justice will be best placed to answer these.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action
Report Sections
Investigation and Inquest
On 27 February 2024 opened the Inquest into the death of Deborah Jane Cooper (Aged 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 TToxicity.
Circumstances of the Death
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 added your predecessor as 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 together by Deborah and which has resulted in her ending_her life
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.