Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0414, written 3 Dec 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Dec 2019 |
|---|---|
| Reference | 2019-0414 |
| Deceased | Callie Lewis |
| Coroner | Patricia Harding |
| Coroner area | Central and South East Kent |
| Category | Suicide (from 2015) · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Rt Hon Nicky Morgan Secretary of State for Digital, Culture, Media and Sport enquiries@culture.gov.uk 1 CORONER I am Patricia Harding, senior coroner, for the coroner area of Central and South East Kent 2 CORONER’S LEGAL POWERS 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. [HYPERLINKS] 3 INVESTIGATION and INQUEST On 28th November 2018 I commenced an investigation into the death of Callie Alix Lewis age 24. The investigation concluded at the end of the inquest on 29th November 2019. The conclusion of the inquest was Suicide by carbon monoxide poisoning contributed to by neglect 4 CIRCUMSTANCES OF THE DEATH Callie Lewis had high functioning Aspergers and depression. She had chronic suicidal ideation and had previously researched methods by which she could die but in the month leading up to her death had been actively planning to end her life. Following three failed attempts to hang herself she changed the method by which she intended to take her life to carbon monoxide poisoning which she believed to be a painless and therefore more likely to succeed. Police attended the address where she was staying when concerns were raised by her family who had learned from a third party of some of the detail of Callie’s plans. The police called the Mental Health team and Callie spoke to them, agreeing to attend the Crisis team the following day. She was assessed and referred to the Community Mental Health team, the level of risk having been assessed as low. Within hours of the assessment Callie was detained under the Mental Health Act by the police who had again been notified of concerns, Callie being found in possession of some of the items from a ‘suicide kit’ which she eventually used to kill herself. Callie was taken to a Mental Health Hospital where she was again assessed, the outcome being that she did not require detention but a referral to the Community Mental Health Team for an assessment to take place the following day. The Community team telephoned Callie when they received the referral but did not take any further action when they were not able to contact her. Callie was reported to the police by the Mental Health Team 12 days after the referral by which time she had already travelled to a remote location and killed herself using a variation of the suicide kit that she had originally been detained with which had been adapted as a result of a failed attempt and following advice gained from a suicide forum. A jury found a number of failures by the Mental Health Team to keep Callie safe which amounted to neglect 5 CORONER’S CONCERNS 1 During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (the forum now (1) Callie was using an online suicide forum, appears under the internet address .Through the forum she was able to engage in discussions with other pro-suicide members and obtain advice how to mislead mental health professionals to avoid being sectioned under the Mental Health Act and also how to perfect the methods of taking her life that she had been considering. She was enabled by the advice provided through the forum to frustrate a mental health assessment and thereafter take her life 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 29th January 2020. 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 Partnership Trust and the Chief Constable of Kent Police. I have also sent it to Samaritans who may find it useful or of interest. , Kent and Medway NHS and Social Care 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 [DATE] 3rd December 2019 [SIGNED BY CORONER] 2
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.
Rt Hon Baroness Morgan of Cotes Secretary of State for Digital, Culture, Media and Sport 4th Floor 100 Parliament Street London SW1 A 2BQ · www ov.uk/dcms I~ January 2020 Our Ref: MC2019/12437/DB Department for Digital, Culture, Media & Sport Patricia Harding Senior Coroner H. M. Coroner for Central and South East Kent Kentandmedwa admin kent. ov.uk b L .,.. tv-. \ 41i ,,....A ·1 · Thank you for your correspondence of 3 December, enclosing your report on the death of Callie Lewis. I would like to extend my sympathies to Callie Lewis's family and friends . Please accept my apologies for the delay in replying to you. I share your concern that young people are at risk of being exposed to harmful content online. These experiences can have a serious psychological and emotional impact, and in tragic circumstances can result in people taking their own lives. I am clear that more needs to be done to protect vulnerable users online and tackle content and behaviour across a comprehensive set of online harms, including content which encourages suicide and self-harm . The Online Harms White Paper, published in April 2019 , set out the government's 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. While some companies have taken steps to address harmful content on their platforms, including to reduce the risk posed by suicide and self-harm related content, these voluntary measures have not delivered the necessary improvements. Under our proposed approach, a new duty of care will 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 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 may also undertake thematic teviews 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 suicide and self-harm related content that provides graphic details of suicide methods and self-harming, including encouragement of self-harm and suicide. Services would be expected to take reasonable steps 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 the regulator could include in a code of practice include setting out the steps a company might take to ensure that users who have been exposed to this content are able to access adequate support; ensuring that companies work with experts in suicide prevention so that their policies and practices protect the most vulnerable; and processes to stop algorithms promoting self-harm or suicide content to users. 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 supportive content to their users. As Secretary of State I do not, however, have the power to prevent the operation of harmful websites. I can assure you that protecting young people'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 Department for Education's Children and Young People's Mental Health Green Paper, published on 4 December 2017, and the government's consultation response published July 2018, 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 held three summits with social media providers last 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 to tackle this content, support vulnerable users of their platforms and improve research and understanding in thi~ area. In addition to this support, the Department for Health and Social Care have allocated £100,000 of seed funding to the strategic partnership. The Cross-Government Suicide Prevention Strategy and Cross-Government Suicide Prevention Workplan published on 22 January 2019, also includes commitments to address suicide and self-harm related content online through the Online Harms White Paper. Being online can be a beneficial experience for young people and users should be able to talk about sensitive topics such as suicide and self-harm. We know that people who are feeling suicidal may use social media and other online forums to reach out for help and support. But more needs to be done to protect users who are vulnerable, and tackle content and behaviour which encourages suicide and self-harm. Our challenge as a society is to help shape an internet that is open and vibrant, and also protects its users from harm. We want to make the UK the safest place in the world to be online, leading international efforts by setting a coherent, proportionate and effective approach that reflects our commitment to a free, open and secure internet. "'"¥'\.~ ~'.A.,~ ~11,..}v'~ Rt Hon Baroness Morgan of Cotes Secretary of State for Digital, Culture, Media and Sport
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