Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0409, written 25 Oct 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Oct 2023 |
|---|---|
| Reference | 2023-0409 |
| Deceased | Bronwen Morgan |
| Coroner | Graeme Hughes |
| Coroner area | South Wales Central |
| Category | Suicide (from 2015) · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
GRAEME HUGHES
HIS MAJESTY’S
SENIOR CORONER
SOUTH WALES CENTRAL
CORONER AREA
CORONER’S OFFICE
THE OLD COURTHOUSE
COURTHOUSE STREET
PONTYPRIDD
CF37 1JW
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
· The Rt Hon Lucy Frazer KC MP, Secretary of State for Digital, Culture, Media and
Sport
· Ofcom
· Eluned Morgan, Welsh Health Minister
CORONER
1
2
3
I am Graeme D Hughes Senior Coroner, for the Coroner Area of South Wales Central.
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.
INVESTIGATION and INQUEST
On 10 September 2020 I commenced an investigation into the death of Bronwen
Grace MORGAN (BM) . The investigation concluded at the end of the inquest 20/10/2023.
The conclusion of the inquest was Suicide.
Toxicity
1a
1b
1c
II
Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
CIRCUMSTANCES OF THE DEATH
Bronwen Morgan had a diagnosis of Emotionally Unstable Personality Disorder. This
manifested itself in fluctuating symptoms including acute periods of distress and anxiety
leading to acts of deliberate self-harm. She was under the care and treatment of local
mental health services. She was engaging in dialectical behaviour therapy the indicated
treatment for Emotionally Unstable Personality Disorder. On 27.8.20 she has travelled to a
hotel possessing a toxic substance that she had purchased
.
4
She was located in the hotel by the emergency services and conveyed to the University
Hospital of Wales, Heath. Despite resuscitation attempts she did not regain consciousness
and died from the toxic consequences of the substance. Material located on her mobile
phone and at the scene demonstrated that she likely intended the consequences of her
deliberate actions to be her own death.
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.
The evidence revealed that as from at least February 2020, BM had registered with, & was
engaging in discussion forums
This website
was mentioned in an earlier PFD Report dated 3.12.19 (copy annexed).
5
The engagement that BM had with the website encompassed her discussing & seeking
advice from fellow users in respect of, methods of self-harm/suicide including the
purchasing & use of the substance
which led to her death.
. This was the substance used by BM
The concern here is that this site & potentially similar self-harm & suicide “facilitating, or
promoting” sites are accessible/available to those, such as BM who are vulnerable, due to
their diagnosed, or otherwise mental illness & provided with an outlet/forum to source &
acquire information that potentially equips them with the knowledge & means to either
complete suicide, or place them in grave/greater danger of doing so.
I believe that consideration ought to be given to the impact such access/availability has
upon those vulnerable individuals researching/contemplating acts of self-harm & whether,
& what action(s) may be taken to remove/limit/mitigate/educate such access/availability.
ACTION SHOULD BE TAKEN
6
In my opinion action should be taken to prevent future deaths and I believe you and your
organisation(s) have the power to take such action.
7 YOUR RESPONSE
Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 20th December 2023, or if I, the Coroner, extends 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 family, the Health Board and Public Health Wales who
may find it useful or of interest.
I am also under a duty to send the Chief Coroner a copy of your response.
8
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.
25 October 2023
SIGNED:
9
Senior Coroner
for South Wales Central Coroner Area
Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
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