Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0404, written 22 Nov 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Nov 2021 |
|---|---|
| Reference | 2021-0404 |
| Deceased | Berenice Bell |
| Coroner | Jonathan Stevens |
| Coroner area | Inner North London |
| Category | Mental Health related deaths · Product related deaths · Suicide (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.
REGULATION 28 REPORT TO .PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Secretary of State for the Department for Digital, Culture, Media & Sport, 100 Parliament St, London SW1A 2BQ 2. The Secretary of State for the Home Office, 2 Marsham Street, London, SW1P4DF 3. Joint Select Committee for the Draft Online Safety Bill 1 CORONER I am JONATHAN STEVENS, Assistant Coroner, for the coroner area of Inner North London · 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. 3 INVESTIGATION and INQUEST On 4th of June Senior Coroner Hassell commenced an investigation into the death of BERENICE NADIKA BELL [age 28). The investigation concluded at the end of the inquest on 12th October 2021. The conclusion of the inquest was that death was a 4 CIRCUMSTANCES OF THE DEATH Berenice had booked into an Airbnb and was found dead in that accommodation on 20th May 2021. She left a note stating . Evidence from a psychotherapist revealed that Berenice had sought psychotherapy help in April 2021. Berenice had no known previous mental history but the consultation with the psychotherapist revealed that she had been feeling anxious and depressed for some time. Berenice also revealed to the psychotherapist that she had attempted to purchase in January/February 2021 with her life savings but had been scammed·and she lost the money and . Berenice booked into an Airbnb accommodation having obtained . She was found dead on 20.5.21 by the owner of the Airbnb having failed to check out of the accommodation. 5 CORONER'S CONCERNS 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. - 1 (1) is the single largest cause of death in the UK for people under 35. (2) Evidence was provided by the family that Berenice had accessed various that provide information and assist people to . (3) The family have discovered through a support group that other parents who family and mental health professionals. have lost their children to children, that their own children were also accessing died. have also discovered, after the deaths of their before they 6 ACTION SHOULD BETAKEN In my opinion action should be taken to prevent future deaths and I believe you AND/OR your organisation 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 17th January 2021. 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 , parents of the deceased. Persons I have also sent a copy the following person who may find it useful or of interest: (Media Adviser), Samaritans, The Upper Mill, Kingston Road, Ewell, Surrey, KT17 2AF. I am also under a duty to send the Chief Coroner a copy of your response. I may also send a copy of your response to any other person who I believe may find it useful or of interest · 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 22nd November 2021 n SIGNED ~ ~ - V 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.
Department for Digital, Culture, Media ~ Sport Jonathan Stevens Assistant Coroner St. Pancras Coroners Court Carnley Street London N1C 4PP · Rt Hon Nadine Dorries MP Secretary of State for Digital,• Culture, Media and Sport 4th Floor 100 Parliament Street London SW1A 2BQ E: engulrjes@dcms.gov.uk www.qov.uk/dcms 6January 2022 Thank you for your email of 23 November, enclosing your report on the death of Berenice Nadika Bell. I would like to extend my sympathies to Berenice Nadika Bell's family and friends. I note that you have also shared your report with the Home Secretary and the Joint Committee scrutinising the draft Online Safety Bill in Parliame'nt. In my previous role as minister for suicide prevention, I met many families who had suffered the devastating loss of a child - and was horrified to find that they had been exposed to awful content online, including online suicide chat rooms or posts encouraging them to harm themselves. This content is inexcusable and companies must take more responsibility for their actions. I share your concerns about the availability of content online that promotes and advertises methods for suicide and self-harm, and we are working across government and with stakeholders, such as the Samaritans, to tackle this serious issue. This case, and sadly several others, has highlighted the need for urgent action in this area. We are taking urgent steps·to protect users, and particularly vulnerable users, online. Under the draft Online Safety Bill, in-scope companies which allow users to post content online or to interact with each other - including social media platforms, websites and search engines - will need to remove and limit the spread of illegal content and activity online. This includes illegal content which encourages or incites suicide online, with all companies in scope of the Bill expected to take swift and effective action ag~inst such content. Companies will need to have effective systems in place to prevent it from appearing on their sites. All -companies in scope of the Bill will also be required to assess whether children are likely to access their services. If so, will have to conduct a child risk assessment and put in place measures to prevent children from being harmed on their service - this includes content that is harmful, even if not illegal. Your report mentions that evidence was provided by the family that Berenice had accessed various suicide websites that provide information and assist people to commit suicide. The scope of the new regulatory framework will apply to services that host user-generated content or facilitate interaction between users. This includes a broad range of services, including social media, forums and marketplaces and search engines. The regulatory framework will apply to any company whose services are targeted at UK users, are used by a significant number of UK users, or which otherwise pose a significant risk of harm to individuals in the UK. It will apply regardless of where the company is based in the world. If any service provider or website owner publishes illegal content, they are already breaking the law by publishing this material. Nevertheless, many people will access these extremely harmful websites through search engines. Under the new regulatory framework, search engines will need to take steps to keep their users safe. This includes identifying keywords that are used to access illegal content, and ensuring illegal content and content that is harmful to children is not promoted through algorithms or predictive searches. Companies whose services have high-risk functionalities, for example., those which enable sharing of content widely and which have the largest audiences, will also be required to take action on content that is legal but which may cause harm to vulnerable adults. If such content is prohibited in their terms and conditions, they must not promote it through their algorithms. These services, known as Category 1 services, will also need to consult expert organisations like the Samaritans about their terms and conditions and undertake regu_lar risk assessments to identify other legal-but-harmful material on these services. Risk assessments will need to consider the risk to adult users, including vulnerable users, such as those at risk of self.;.harm or suicide for example. Category 1 services will then need to set out in clear terms and conditions what is acceptable on their services in relation to legal-but-harmful content, and enforce those terms and COl")ditions consistently and transparently. Folloyving consultation with Ofcom, a limited number of priority categories of content that pose the greatest risk to users will be set out in secondary legislation. There will be three categories of priority harm: criminal offences, legal but harmful content affecting adults and . harmful content affecting children. Work is still ongoing to determine the composition of these lists but we are confident that the list of priority legal-but:-harmful offences is likely to include suicide, self-harm and eating disorder-related content. If a company fails its duties, it coµld face enforcement action. It could be liable for fines of up to 10 per cent of annual turnover or £18 million, whichever is higher. The enforcement powers, also including business disruption measures, have been designed to be effective against companies with and without a physical or legal presence in the UK. The regulator, Ofcom, will have the power to apply to the courts to restrict non-compliant services from being accessed in the UK. Alongside enforcement powers, Ofcom will have aduty to consider the vulnerability of users whose circumstances appear to put them in need of special protection when performing its duties. The draft Bill has been subject to pre-legislative scrutiny by a Joint Committee. The Joint Committee reported with their recommendations on 14 December. We will now fully consider the Committee's recommendations and are committed to introducing the Bill as soon as possible after that. In the meantime we are working closely with Ofcom to ensure that the implementation of the framework is as short as possible, following passage of the legislation. We are also ensuring that criminal !aw is fit for purpose to account for harmful and _. dangerous communications online. The Department for Digital, Culture, Media and Sport sponsored a Law Commission review of harmful online communications. As part of this review, the government has asked the Law Commission to examine how the criminal law will address the encouragement or assistance of self-harm. The Law Commission has published its final report, recommending several new or replacement offences to capture these types of communications online, including a new self-harm offence: The government is considering the Law Commission's recommendations and will set out our position in due course. , The Department for Health and Social Care's strategic partnership with suicide and self harm prevention experts, led by the Samaritans, continues to tackle this content and support vulnerable users of their platforms. This partnership is undertaking research to develop our understanding of harmful suicide and self-harm content, produce guidance for industry and establish an advice and reporting service. Samaritans have also released Managing self-harm and suicide content online, a set of guidelines for sites and platforms hosting user-generated content, which sets out a framework of best practice principles to support platforms to manage self-harm and suicide content in a safe and sensitive way. The government continues to engage with these stakeholders as part of wider suicide .prevention work and the online safety framew9rk. Rt Hon Nadine Dorries MP Secretary of State for Digital, Culture, Media and Sport
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