Prevention of Future Deaths reports · 2023

Gary Cooper

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 report12 Jan 2023
Reference2023-0015
DeceasedGary Cooper
CoronerRobert Cohen
Coroner areaCumbria
CategorySuicide (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.

Kally Cheema LLB | Senior Coroner| Cumbria 

Fairfield, Station Road, Cockermouth, Cumbria CA13 9PT 

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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 

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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 

 . 

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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. 

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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

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 Department of Health and Social Care (PDF)
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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