Prevention of Future Deaths reports · 2021

Berenice Bell

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 report22 Nov 2021
Reference2021-0404
DeceasedBerenice Bell
CoronerJonathan Stevens
Coroner areaInner North London
CategoryMental Health related deaths · Product related deaths · Suicide (from 2015)
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

Responses

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.

Response from Dept for Digital Culture Media Sport (PDF)
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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