Bronwen Morgan
PFD Report
Historic (No Identified Response)
Ref: 2023-0409
Coroner's Concerns (AI summary)
Vulnerable individuals are able to access websites that facilitate and promote self-harm and suicide methods, enabling them to acquire information and means to cause their own death.
View full coroner's concerns
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.
Sent To
- Department for Digital, Culture, Media and Sport
- Ofcom
- Welsh Health Minister
- Welsh Health Minister
Response Status
Linked responses
0 of 4
56-Day Deadline
20 Dec 2023
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
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
Circumstances of the Death
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 the indicated treatment for Emotionally Unstable Personality Disorder. On 27.8.20 she has travelled to a hotel possessing a toxic substance that she had purchased .
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.
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.
Action Should Be Taken
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by 20th December 2023, or if I, the Coroner, extends the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
You are under a duty to respond to this report within 56 days of the date of this report, namely by 20th December 2023, or if I, the Coroner, extends the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
Copies Sent To
Health Board and Public Health Wales
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.