Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0207, written 29 Apr 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Apr 2019 |
|---|---|
| Reference | 2019-0207 |
| Deceased | Bradley Trevarthen |
| Coroner | David Ridley |
| Coroner area | Wiltshire and Swindon |
| Category | Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
David Ridley HM Senior Coroner for Wiltshire and Swindon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Ms. Margot James MP Minister for Digital & the Creative Industries Department for Digital, Culture, Media & Sport 100 Parliament Street LONDON SW1A2BQ 1 CORONER I am David Ridley, HM Senior Coroner for Wiltshire and Swindon 2 CORONE~SLEGALPOWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.qov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.qov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On the 11 January 2018 I commenced an investigation into the death of Bradley Robert Michael Trevarthen, and an Inquest into his death was opened by me on the 18 January 2018. On the 25 April 2019 I concluded Brad's Inquest. I found that the medical cause of death was 1a) Hanging. In box 3 in the Record of Inquest I recorded how, when and where Brad came by his death as follows :- At some point after 1541 on Wednesday 10 January 2018 Bradley hanged himself by the neck at his home in Durrington, Wiltshire . He was discovered at around 1640 and despite advanced life support measures was confirmed as having died at 1812 at Salisbury District Hospital in Wiltshire the same day. Having considered the evidence I felt that there was insufficient evidence to make a finding of fact that on a balance of probabilities that Brad had intended to take his life at that time and I therefore recorded as a conclusion one of - Accident . Such a conclusion is recorded were a finding is made that someone has died , as in Brad's case, as a result of an unintended consequence of a deliberate act. 4 CIRCUMSTANCES OF THE DEATH It is fair to say that all unnatural deaths generally speaking are tragic but in the case of Brad it is even more tragic because Brad was a schoolboy and at the time of his death was aged 13. HavinQ left school for the day on Wednesday 10 January 2018, Brad was subsequently found by Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SPl lDP Tel 01722 438900 I Fax 01722 332223 his younger sister suspended from the bannister at his home in Durrington in Wiltshire at approximately at 1640 the same day. At about an hour earlier he had lnstagrammed a friend in respect of which he was aware that a school friend of his had spoken to a teacher earlier that day and he was hopeful that he would get some support and help. A couple of Brad friends had become increasingly concerned for Brad especially following their return to school about a week earlier and had spoken to the Head of Year that morning. I was satisfied having heard the evidence that an immediate risk of harm was not conveyed to the Head of Year and in fact one of the students who spoke with the teacher in evidence indicated that he personally did not think that Brad would go through with his actions and take his own life. The evidence was clear that shortly before the return to school, for the Spring term, that Brad's outlook had changed and when talking about self-harm and suicide Brad's tone took a more serious nature and this ultimately was of concern to his friends. As I sure you are aware communication these days is not simply face to face and in the digital age there are many internet based communication platforms that people, especially young persons, use to communicate and one of those platforms was Discord and before returning to school Brad appeared to be expressing thoughts of taking his own life and this continued whilst gaming following their return to school. He actually indicated that he had made an attempt 2 days earlier but his friends for fear that their parents would ban them from using their electronic equipment did not communicate this to anybody. What was apparent from the evidence was that Brad was becoming increasingly aware of the concept of suicide and exploring methods. There was evidence that pointed to him if not directly (You Tuber) of a Japanese Forest where people viewing the video footage taken by hang themselves, that he did enter and view discussions on the subject and also entered other discussions boards such as Reddit where suicide was being advocated for and advocated against and where methods were being discussed. It was clear to me that Brad was developing an unhealthy interest in relation to the concept of suicide and the means to achieve one's own death. The reason why I did not return a suicide conclusion was primarily having regard to the lnstagram message that Brad sent to his friend approximately an hour before he was found which did not point to an immediate risk of death and no note was left at the time. I found more likely than not that Brad was experimenting with the method, however, it is not commonly known that having placed an ligature around ones neck that it can compress nerves and blood vessels that can lead to unconsciousness in a matter of seconds and unless there is somebody there to cut you down the likely outcome is death. 5 CORONE~SCONCERNS It will come as no surprise that my concern here relates to the internet and the regulation of it. Brad had access to the worldwide web however as with other cases that I am sure you are aware of that have been highlighted of late, my concern here is that some of the material Brad was exposed to was of a nature that a young person of his age should not be exposed to as they cannot, in my view, properly assimilate and process the information that they view. The amount of information on the subject of self-harm and suicide that is currently available to young persons on the internet goes beyond freedom of expression and I am concerned that the extent of such It is not information Normalises actions which at the end of the day are simply not normal. normal to self-harm and it is not normal to perform an act which results in that person's own death. I fully appreciate that the responsibility does not rest solely with Parliament, but the control of this entity has to start somewhere although I fully accept that to counter such activity will involve the combined efforts of Parliament, internet service providers, internet site owner, schools and colleges, parents/guardians as well as the young person's themselves. I can take judicial notice of when I was growing up that I do not recall ever discussing self-harm and suicide in the same way as it is discussed now, and I fear that the abundance of this type of information and the ease of its accessibility is leading to this concept of Normalisation of such actions . Yes, it is totally riqht that we should be open about mental health issues but the Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SPl lDP Tel 01722 438900 I Fax 01722 332223 abundance of information that is out there on self-harming and suicide methods is a step too far hence my concern. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 24 June 2019. I, the coroner, may extend 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Dated 29 April 2019 - Signature _ _____.::"-��=:'-�---=-�' "'\ - ...... .---.... David W. G. Ridley HM Senior Coroner for Wiltshire and Swindon Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SPl lDP Tel 01722 438900 I Fax 01722 332223
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Margot James MP PR Minister for Digital and the Creative Department for “Tondon SWIA 280 Digital, Culture, E: enquirie: Iture.gov.uk Media & Sport www.gov.uk/dems David W.G. Ridley ZYhJune 2019 HM Senior Coroner for Wiltshire and Swindon WSCoronersOffice@wiltshire.gov.uk Our Ref: INV2019/04254 beew Mw Reel Thank you for your correspondence of 29 April providing your Regulation 2B Report to Prevent Future Deaths following the tragic death of Bradley Robert Michael Trevarthen. | would like to extend my deepest sympathies to the Trevarthen family. The loss of someone so young is always a terrible tragedy. The government shares your concern that children are at risk of being exposed to harmful content online. These experiences can have serious psychological and emotional impact. We are clear that more needs to be done to protect vulnerable users and tackle content and behaviour across a comprehensive set of online harms, including content which encourages suicide and self-harm. That is why on 8 April we published our Online Harms White Paper (https://www.gov.uk/government/consultations/online-harms-white-paper) which sets out our plans for world-leading legislation to make the UK the safest place in the world to be online. This will make companies more responsible for their users’ safety online, especially children and other vulnerable groups. The government will establish a new statutory duty of care to make companies take more responsibility for the safety of their users and tackle harm caused by content or activity on their services. Compliance with this duty of care will be overseen and enforced by an independent regulator. The regulator will set clear safety standards, backed up by mandatory reporting requirements and sufficient powers to take effective action against companies that breach regulatory requirements, including the power to levy substantial fines. The regulator will have the power to require annual reports from companies, as well as require additional information from them to inform its oversight or enforcement activity, and to establish requirements to disclose information. It may also undertake thematic reviews of areas of concern, for example a review into the treatment of self-harm or suicide related content. The regulator will have the power to require companies to share research that they hold or have commissioned that shows that their activities may cause harm. All companies in scope of the regulatory framework will need to be able to show that they are fulfilling their duty of care. This will include a requirement for companies to take robust action to address harmful suicidal and self-harm content that provides graphic details of suicide methods and self-harming, including encouragement of self-harm and suicide. Services must also respond quickly to identify and remove content which is illegal or violates terms of use, and act swiftly and proportionately when this content is reported to them by users. Some of the areas we expect the regulator to include in a code of practice include: e Steps to ensure that vulnerable users and users who actively search for, or have been exposed to, this content are directed to, and able to access, adequate support e Ensuring that companies work with experts in suicide prevention to ensure that their policies and practices are designed to protect the most vulnerable; e Steps companies should take to ensure that their services are safe by design, including tools to help users avoid material or behaviour which encourages suicide or self-harm e Guidance about how to ensure it is easy for users to understand these tools, and the company’s terms of use in relation to these harms, when they sign up to use the service e Processes to stop algorithms promoting self-harm or suicide content to users « Measures to ensure that reporting processes and processes for moderating content and activity are transparent and effective at tackling the encouragement of self-harm and suicide and measures to ensure that users are kept up to date with the progress of their report e Steps services should take to ensure they engage sufficiently with civil society groups and law enforcement, so that moderators are educated about what constitutes self-harm or suicide encouragement and how it can be prevented and tackled e Steps companies should take to ensure harm is tackled rapidly, such as removing content which is illegal or violates acceptable use, and blocking users responsible for activity which violates terms and conditions, as well as steps that services can take to ensure that these measures are conducted sensitively e Steps to prevent banned users creating new accounts to continue to encourage suicide or self-harm While it will be for the new regulator to produce codes of practice when it becomes operational, the government expects companies to take action now to tackle harmful content or activity on their services. Indeed, there are already some existing arrangements between individual companies and charities to improve the identification and removal of this content when it is reported, and services that signpost help and promote supportive content to their users. It is also worth noting that being online can be a beneficial experience for children and young people, and online users should be able to talk about sensitive topics such as suicide and self- harm. The internet holds significant potential benefits to prevent suicide and we know that people who are feeling suicidal may use social media and other online forums to reach out for help and support. The Department for Education (DfE) continues to incorporate online safety into the school curriculum, to help children and young people improve their digital literacy to equip them to manage the different and escalating risks that young people face. As part of this, DfE is making Relationships Education compulsory for all primary pupils, Relationships and Sex Education compulsory for all secondary pupils and Health Education compulsory for all pupils in all primary and secondary state-funded schools in England. These subjects will include teaching about respectful relationships, including online, as well as health and mental wellbeing. | can assure you that protecting children’s mental health is a priority across government and a core part of the NHS Long Term Plan. The NHS has set a goal of an extra 345,000 children and young people (aged 0-25) receiving support via NHS-funded mental health services by 2023/24. The Department for Health and Social Care and DfE’s Children and Young People’s Mental Health Green Paper (https://www.gov.uk/government/consultations/transforming-children-and- young-peoples-mental-health-provision-a-green-paper), published on 4 December 2017, and the government's consultation response published last July, considers the impact of social media on young people’s mental health. As highlighted in the green paper, we have convened a working group of social media and digital sector companies to explore what more they can do to help us keep children safe online. The Secretary of State for Health and Social Care and the Minister for Mental Health, Inequalities and Suicide Prevention have also held two summits with social media providers this year about suicide and self-harm content on their platforms. Following these meetings, social media companies have committed to increasing their efforts to protect users by establishing, and funding, a strategic partnership with suicide and self-harm prevention experts, led by the Samaritans, to tackle this content and support vulnerable users of their platforms. The Cross-Government Suicide Prevention Strategy and Cross-Government Suicide Prevention Workplan (https://www.gov.uk/government/publications/suicide-prevention-fourth- annual-report) published on 22 January this year, also includes commitments to address suicidal and self-harm content online through the Online Harms White paper. | hope this information reassures you that the government is taking significant steps to protect children and young people from harmful content online. Marca James Margot James MP Minister for Digital and the Creative Industries PS |} Wold Ihe +0 wndourol Wy WB, Owe ropot oy tha tragic lo Sr this ‘ Sys of np Youn li » this whaehd a ten ble iwAictuiad o4 te Lr ed3i ne CMU - AB, SG s s BYYs & & 4°
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