Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0015, written 12 Jan 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Jan 2023 |
|---|---|
| Reference | 2023-0015 |
| Deceased | Gary Cooper |
| Coroner | Robert Cohen |
| Coroner area | Cumbria |
| Category | 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.
Kally Cheema LLB | Senior Coroner| Cumbria Fairfield, Station Road, Cockermouth, Cumbria CA13 9PT 1 2 3 4 12 January 2023 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (1) The Secretary of State for Culture Media and Sport and (2) The Secretary of State for Health and Social Care CORONER CORONER I am Robert Cohen, HM Assistant Coroner for Cumbria 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 6 July 2022 I commenced an investigation into the death of Gary Dennis COOPER. The investigation concluded at the end of the inquest . The conclusion of the inquest was Suicide 1 CIRCUMSTANCES OF THE DEATH Gary Cooper was 41 years old. He lived in Kendal, Cumbria. He suffered from depression and psychosis. On 3rd July 2022 Mr Cooper was found at home. He was unresponsive. An ambulance attended but resuscitation was not possible; Mr Cooper's death was confirmed at 15:15. A post mortem examination has confirmed that Mr Cooper died as a result of having ingested . 5 2 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. - (1) (2) . 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 8 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 9th March 2023. 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to Mr Cooper's family. 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. 12 January 2023 9 Signature Robert Cohen HM Assistant Coroner for
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 Maria Caulfield MP Parliamentary Under Secretary of State Department of Health & Social Care 39 Victoria Street London SW1H 0EU Thursday 29th June 2023 Mr Robert Cohen – Assistant Coroner for Cumbria HM Coroner's Office Fairfield, Station Road Cockermouth CA13 9PT Dear Robert, Thank you for your correspondence of 12 January to the Secretary of State for Culture, Media and Sport and the Secretary of State for Health and Social Care about the death of Gary Dennis Cooper. As you will know, the Department for Science, Innovation and Technology now has responsibility for online safety and I am replying on behalf of both Departments as the Minister with responsibility for mental health and suicide prevention at the Department of Health and Social Care. Firstly, I would like to say how deeply saddened I was to read of the circumstances of Mr Cooper’s death. I can only begin to imagine the effect that this will have had on his loved ones and, whilst I know that it will come as little comfort to them, I nevertheless hope they will accept my heartfelt condolences. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. It is important that we limit the spread of information about emerging methods of suicide. As such, my reply does not make direct reference to the substance used in this case, nor link to information about it, and I hope that, when making Regulation 28 reports and responses to them publicly available, the Chief Coroner and his office will practise similar caution. With regard to the sale of the substance used in this case, Departmental officials work closely with the Home Office on this matter and I understand from them that this substance is available to the public for legitimate uses. It is, however, included in The Poisons Act 1972 as a reportable substance, meaning that while it is generally available without the need for a licence, sellers (including online sellers) are obligated to make suspicious transaction reports, whether they process the transaction or not, where they have grounds to believe that the sale is for an illicit use. The Home Office regularly engages with suppliers to help them meet their requirements under the Poisons Act, and to provide detailed guidance in relation to any additional safeguarding steps they may wish to take. It achieves this in a number of ways including by regulating, raising awareness and asking businesses to be more vigilant. Generally, online marketplaces maintain their own policies on prohibited items, many of which will include a prohibition on the sale of poisons. It is the seller’s obligation to check that items they are listing are permitted by their own policies and to take any action where it is appropriate. Online marketplaces will remove listings that contravene their prohibited items list when notified. I share your concerns about the accessibility of websites that provide information on suicide methods and I can assure you that the Government is taking action to restrict access to them. The Online Safety Bill, which is currently making its way through Parliament, is a major milestone in the Government’s mission to make the UK the safest place in the world to be online and will address the threat from many of these sites. Under the Bill, where a website hosts user-generated content and has information that promotes, encourages or provides methods for suicide, it will be in scope of the Bill’s regulatory framework. This includes sites which are ‘linked to the UK’ i.e. sites that have a significant number of UK users or present a material risk of significant harm to UK individuals. In line with the Bill’s regulatory framework, these sites will need to proactively prevent users from being exposed to priority illegal content, including content that encourages or assists suicide where it meets the criminal threshold under the Suicide Act 1961 offence. Further, all companies in scope will also need to remove and limit the spread of any other illegal content in scope of the Bill when it is flagged to them or they become aware of it. They will be required to have effective and accessible mechanisms for users and affected persons to easily report concerns and seek redress. We understand the serious concerns around pro-suicide and self harm sites and know that internet traffic to these sites is often driven by search results. The Bill therefore places duties on search engine services to minimise access to illegal content by requiring them to minimise the likelihood of a person accessing illegal content via search results, which should in turn reduce traffic to sites that include content that encourages or assists suicide. Search engines will also have duties in respect of illegal harmful content impacting children. Beyond these protections, the Bill has additional measures to help adult users stay safe online. Major tech companies will need to adhere to their terms of conditions, including where they state that they prohibit suicide and self-harm content. The transparency, accountability and freedom of expression duties in the Bill will ensure that Category 1 (the largest) services are clear to their users about what they will and won’t allow on their services. If these services state that they do not allow this content in their terms of service, even if it is a link to such content hosted on a pro-suicide site, then they will have to remove it. Many platforms already state that they prohibit pro suicide and self-harm content, however the Bill will ensure that these terms of service are properly enforced, and users will be able to access a complaints mechanism if they believe that companies are not keeping their promises to users. In addition, the Bill’s user empowerment duties will give adults greater control over the content that they see on Category 1 platforms. When applied, these tools will reduce the likelihood that users encounter certain types of content, such as suicide and self harm content, or will alert them to the nature of it. It will support all users and particularly, vulnerable users, better control their online experience and limit their exposure to damaging content. If a service fails in its duties, it could face enforcement action from Ofcom, and could be liable for fines of up to 10 percent of global annual qualifying turnover or £18 million, whichever is higher. I also want to make you aware of the Government’s commitment to take forward a new self-harm communications offence, which will add a further layer of protection, on top of those in the Bill’s regulatory framework. The offence will capture communications that intentionally encourage or assist serious self-harm. The new criminal law will protect all potential victims - children as well as adults - and will capture communications online as well as offline. Once the offence is introduced, all companies will have to remove such content. The Department chairs an emerging methods working group, with representatives from our partners in the Voluntary, Community and Social Enterprise sectors, to enable us to rapidly identify and proactively tackle emerging methods of suicide as quickly and effectively as possible, with a series of interventions to reduce access and awareness. This includes actions to minimise awareness of and tackle the sale of this substance for the purpose of suicide. Members of this group continue to monitor online forums for self-harm and suicide content that may include future emerging methods. In addition to this, the group continues to work with the media and online platforms to try and reduce the availability of information about emerging methods of suicide. This has led to the substance name being removed from articles where it was originally named. Turning to protecting people who are trying to purchase items that might be used for the purposes of taking their life and, more broadly, supporting people online who may be experiencing suicidal ideation and at crisis point, we support our partners across the voluntary sector to engage with search engines and online platforms to minimize the availability of harmful, suicide-related content online. Finally, it is vital that we continue to take action nationally and in local areas to prevent suicides. We are investing an additional £57 million in suicide prevention by march 2024 through the NHS Long Term Plan. Through this, all areas of the country are seeing investment to support local suicide prevention plans and the development of suicide bereavement services. We know that as many as two thirds of people who take their own life are not known to mental health services or have not had contact with those services for at least a year prior to death. This is why it is important that local communities have suicide prevention plans that take into consideration their local populations. Every local authority has a multi-agency suicide prevention plan in place and, in 2021/22, we provided over £550,000 to the Local Government Association for a support programme to help local authorities strengthen their plans. In addition to this, when there are particular concerns about suicides, such as clusters or new and emerging methods, regional mental health leads in the Office for Health Improvement and Disparities work with the relevant local authorities to provide support on how to respond based on national guidance. We have committed to publish a new national suicide prevention strategy later this year and are engaging widely across the sector to understand what further action we can take to reduce cases of suicides. I know this reply will come as little consolation to Mr Cooper’s family. I nevertheless hope it assures them that we are aware of the serious matters raised by Mr Cooper’s death and we are taking steps across Government and with the suicide prevention sector to prevent future tragic losses of life from occurring. Thank you for bringing these concerns to my attention. Yours sincerely, MARIA CAULFIELD MP
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