Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0086, written 18 Mar 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Mar 2022 |
|---|---|
| Reference | 2022-0086 |
| Deceased | James Forryan |
| Coroner | Edwin Buckett |
| Coroner area | Inner North London |
| Category | Mental Health related deaths · Suicide (from 2015) · Alcohol, drug and medication 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: Prevention of Future Deaths report James Forryan (died 29.10.2021) THIS REPORT IS BEING SENT TO: (1) Rt Hon Gillian Keegan MP (Minister for Care and Mental Health) House of Commons London SW1A 0AA (2) Professor Director of the National Inquiry into Suicide and Safety in Mental Health University of Manchester Oxford Road Manchester M13 9PL 1 CORONER I am: Edwin Buckett Assistant Coroner Inner North London Poplar Coroner’s Court 127 Poplar High Street London E14 0AE 2 CORONER’S LEGAL POWERS I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. 3 INVESTIGATION and INQUEST On the 8th November, 2021 Assistant Coroner Sarah Bourke began an investigation into the death of James Forryan who died aged 29, on the 29th October, 2021 at the Novotel Hotel, 40 Marsh Wall, London E14. The investigation concluded at the end of the inquest on 15th March, 2022 conducted by myself, Assistant Coroner Edwin Buckett. 1 I made a determination at inquest that the deceased died as a result of suicide which was caused by him deliberately taking a poisonous quantity of pentobarbital medication. 4 CIRCUMSTANCES OF THE DEATH James Forryan was a young man with a mild history of depression and anxiety. On the 28th October 2021 he checked into a hotel in London and took at the fatal dose of pentobarbital medication which caused his least death on the 29th October 2021 whilst staying at that hotel. The post-mortem and toxicology evidence revealed that his death was caused by a pentobarbital overdose. 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 will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. Evidence was given that: 1. James had accessed a forum on the internet known to promote suicide. That website and the forum discussions attached to it provided advice and guidance on: (i) Appropriate drugs/medication which would produce a terminal result; (ii) Which drugs were most effective; (iii) How they should be taken; (iv) How they could be purchased;. (v) End of life planning. 2. James was careful and methodical in the actions he took to end his life. He appeared to follow some guidance on the steps to take from a “handbook” which the family believe was generated from a suicide promoting website and his decision to acquire the pentobarbital medication was informed by the that website. 3. The suicide promoting website appeared to act as a trigger in his decision to take his own life. I am concerned that: 2 (a) There are websites and forums which openly promote and advertise methods of suicide which are easily accessible; (b) Suicide is the largest cause of death for individuals in the UK under the age of 35 and James Forryan is within that age bracket; (c) There does not appear to be sufficient regulation or enforcement action against such websites which promote criminal offences and/or harmful content. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that 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 27th May 2022. 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 following. • HHJ Thomas Teague QC, the Chief Coroner of England & Wales • , the parents of James Forryan. I am 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 18.3.2022 SIGNED BY ASSISTANT CORONER 3 Edwin Buckett 4
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.
From Rt Hon Maria Caulfield MP Parliamentary Under Secretary of State for Mental Health and Women’s Health Strategy 39 Victoria Street London SW1H 0EU 16 November 2022 PFD-1401677 Edwin Buckett Assistant Coroner Inner North London Poplar Coroner’s Court 127 Poplar High Street London E14 0AE Dear Mr Buckett, Thank you for your letter of 18 March 2022 to the then Minister for Care and Mental Health Gillian Keegan, about the death of James Forryan. I am replying as Minister with responsibility for Mental Health, and thank you for the additional time allowed. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Forryan’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning. Preventing suicide is an extremely important part of my portfolio, and I am grateful to you for bringing this issue to my attention. As you highlight in your report, it is true that suicide is the leading cause of death in the UK amongst people aged 20-34,1 this is a concerning statistic and highlights the importance of doing all that we can to support individuals who may be experiencing harmful or suicidal thoughts. Every suicide is a preventable loss, and I assure you that it remains a priority for the Government and for me personally, that we take action to reduce suicide rates as far as possible. To address your concern around websites promoting criminal offences and/or harmful content, we are taking urgent steps to protect users, and particularly vulnerable users, online. The Government is committed to tackling this and making the UK the safest place in the world to be online. Under the Online Safety Bill, in-scope companies that allow users to post content online or to interact with each other – including social media platforms and online forums – will need to remove and limit the spread of illegal content and activity online. This includes illegal content that encourages or incites suicide online, with all companies in scope of the Bill expected to take swift and effective action against such content. Companies will need to have effective systems in place to prevent it from appearing on their sites. In addition, the Government has now confirmed that encouraging or assisting suicide will be listed as a priority illegal offence in the Bill, alongside other offences such as incitement to and threats of violence. However, I am also aware that the implementation of legislation takes time, during which individuals, some of whom may be experiencing harmful or suicidal thoughts, will potentially 1 ONS, Leading causes of death, UK: 2001 to 2018, March 2020: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/causesofdeath/articles/l eadingcausesofdeathuk/2001to2018 be exposed to extremely harmful and inciting online content. In advance of the legislation coming into force, we are working with online platforms to encourage action to remove or reduce access to harmful suicide and self-harm material. The Department works closely with the Samaritans who have in place a strategic partnership with suicide and self-harm prevention experts, which continues work with platforms to tackle harmful suicide and self-harm 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 has established an advice and reporting service. Samaritans have also released Managing self-harm and suicide content online2, 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 framework. We are also investing £57 million in suicide prevention through the NHS Long Term Plan. This will see investment in all areas of the country by 2023/24 to support local suicide prevention plans and establish suicide bereavement support services. We have also issued guidance to local authorities that highlights the importance of working across all local services, including the voluntary sector, to target high risk groups, including men and children and young people. In addition, in 2021/22, we provided £5.4million to Voluntary, Community and Social Enterprise organisations to support the sector to continue to meet increases in demand as a result of the pandemic. This included funding to a number of organisations with a particular focus on addressing the needs of children and young people, including Papyrus, a national suicide prevention charity that works to prevent suicide amongst people under 35 by providing confidential support and advice to young people struggling with thoughts of suicide. The funding also reached a number of organisations focusing on suicide prevention amongst men. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MARIA CAULFIELD MP 2 https://media.samaritans.org/documents/Online_Harms_guidelines_FINAL.pdf CC: Rt Hon Michelle Donelan MP Secretary of State for Digital, Culture, Media and Sport
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