Chloe Macdermott

2 February 2024  

Dear Mr Rogers,  

Re: The Inquest Touching the Death of Chloe Elizabeth MACDERMOTT 
A Regulation 28 Report – Action to Prevent Future Deaths 

In  response  to  your  report  dated  19  December  2023  (the  “Report”),  please  find  below  our  written 
response in accordance with paragraph 7(2) of Schedule 5 to The Coroners and Justice Act 2009. 

Thank you for sharing with us your Report and for bringing to our attention your findings and concerns. 
We are greatly saddened to hear about the death of Chloe Elizabeth MacDermott and we extend our 
deepest  condolences  to  her  family.  We  understand  your  report  refers  to  cause  of  death  as  being 
‘sodium  nitrate/nitrite  toxicity’.  Amazon’s  UK  Store  prohibits  the  sale  of  poisons  as  defined  under 
Schedule  1A  of  the  UK  Poisons  Act  1972.  This  includes  high  concentration  sodium  nitrate  and  high 
concentration sodium nitrite mixtures/substances. More details can be found here.  

As you may know, in many other jurisdictions, sodium nitrite is a legal and widely available product 
offered by retailers to preserve foods (such as meats and fish) and for use in laboratories as a reagent. 
High concentration sodium nitrite is not intended for direct consumption, but unfortunately, like many 
products, it can be misused.  

At Amazon we work hard to earn and maintain customer trust, meaning that safety is a top priority for 
us. Last year, we invested  more than  $1.2 billion  to protect our stores  and  our customers, building 
robust safety and compliance programs. We are constantly iterating and improving upon our approach. 
Since October 2022, we have globally restricted the sale of high concentration sodium nitrite to Amazon 
Business  customers  (which  is  solely  focussed  on  business-to-business  transactions)  to  minimize  the 
potential for product misuse. Therefore, in countries where Amazon Business is not yet available or 
where local policies prohibit such sale (such as the UK store), high concentration sodium nitrite is not 
available for purchase.  

We trust this is helpful and again express our sincere condolences to Ms. MacDermott’s family for their 
tragic loss. 

Please do let us know if you require any further information. 

Yours sincerely, 

VP UK Country Manager 

AMAZON UK SERVICES LIMITED 
1 PRINCIPAL PLACE, 115 WORSHIP STREET, EC2A 2FA, LONDON 
Tel. 44 (0)20 3680 1000 
WWW.AMAZON.CO.UK

OFFICIAL

12th February 2024  

“Mr Rogers,  

Thank you for your correspondence to Assistant Chief Constable 

, British 

Transport Police in the Regulation 28 Report dated 19th December 2023 concerning the sad death of 
Chloe Elizabeth Macdermott.  

May I first express my deepest condolences to Chloe’s family, friends and loved ones.  

ACC 

 is the National Police Chief Council’s lead for Suicide Prevention by virtue 

of him being the current chair of the NPCC Suicide Prevention Steering Group. Under ACC 
leadership, the Steering Group aims to foster collaborative partnerships across England, Wales, and 
Scotland. The Steering Group’s focus is on understanding, responding to, and preventing suicide, 
aligning with the NPCC Policing Vision 2025. The Steering Group's purpose includes developing a 
comprehensive understanding of suicide trends, formulating prevention strategies, providing a 
platform for networking and collaboration, establishing an evidence-based foundation for effective 
tactics, and offering guidance for a nationally consistent approach to suicide prevention. Through this 
work, ACC 
purchasing materials on international sites on the internet, particularly Sodium Nitrate and Nitrite, for 
the suspected purpose of suicide. Currently intelligence is suggesting that the purchase and use is 
decreasing however it still remains a concern.  

 has been made aware of recent concern and increase in the number of people 

’s 

In collaboration with experts from the Department for Health and Social Care (DHSC), Home 

Office and other key stakeholders, NPCC Suicide Prevention Steering Group members have raised 
awareness and informed responses across the policing sector regarding the emerging trend of 
Sodium Nitrate and Nitrite use in suicides. We have also supported the National Crime Agency, which 
is conducting a criminal investigation into the supply of Sodium Nitrite by a specific foreign national 
and working closely with the CPS and international authorities. 

In the UK Sodium Nitrate and Nitrite are reportable substances (Sodium Nitrate as an 
Explosive Precursor and Sodium Nitrite as a Reportable Poison) under the Poisons Act. Given recent 
events, ACC 
 has discussed the regulation or restriction of Sodium Nitrate and Nitrite with the 
Home Office’s Chemical Reporting Team and the Dept of Health and Social Care have taken work 
forward to ensure as far as possible that both Sodium Nitrate and Nitrite is not sold to individuals. 
Legal suppliers have been directed to mix the substances with other products namely salt which will 
lead to vomiting upon ingestion. We have been advised that there are no current plans to change 
Sodium Nitrate or Nitrite status from 'reportable'. The Home Office, in collaboration with legitimate 
suppliers, is proactively challenging suspicious sales. Some suppliers are considering a mixed 
product formulation to induce vomiting upon ingestion, thereby reducing the viability of Sodium Nitrate 
or Nitrite as a suicide method.  

In October 2023, legislative changes were made regarding the sale of poisons and explosive 

precursors by suppliers based in England, Wales and Scotland. These changes, which include 
substances which are classed as reportable Explosive Precursors like Sodium Nitrate or Poisons like 
Sodium Nitrite, aim to reduce the risk of harm by setting out obligations for suppliers related to 
regulated and reportable substances. As of 1st October 2023, it is now a criminal offence to sell 
certain substances without an Explosives Precursors and Poisons (EPP) license.  

When specific intelligence indicates that an identifiable individual in the UK has purchased 

items like Sodium Nitrate and Nitrite, police will conduct a ‘safe and well’.  Often, voluntary surrender 
of these items can be negotiated, with recovery and appropriate support referrals made. Where this is 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 OFFICIAL

not possible, increased health surveillance measures are encouraged with partner agencies. In cases 
of death linked to chemical suicide, efforts are made to track shipments and download electronic 
devices to quickly identify the product's origin and prevent further victims.  

Regarding police powers of entry, search, and seizure, Section 19 of PACE allows for the 

seizure of ‘evidence’ when an offence is established or suspected. However, the offence of 
Encouraging or Assisting Suicide, as per the Suicide Act 1961 (amended 2010) is complex. This is 
particularly true when the perpetrator operates from outside the UK, and/or the 'victim' is an active and 
willing participant. In such scenarios, the law is unclear, and there is no power of entry to a victim’s 
premises unless an immediate threat to life is believed to exist under Section 17 of PACE. Identifying 
and seizing potential self-harm items in a typical household is impractical due to the ubiquity of such 
items.  

ACC 

 is aware of and remains concerned of the number of on line suicide and self harm 

content sites. Sites such as Sanctioned-Suicide are incredibly concerning and as a result the NPCC 
have been working closely with Government colleagues to create and implement actions of which 
there are many to reduce and restrict access to such websites. 
The Governments new five-year Suicide Prevention Strategy for England, recently launched last year, 
contains numerous actions that will enable all relevant and influential organisations to support and 
achieve Government ambition. Whilst the Government is taking the lead in Suicide Prevention across 
England, working an collaborating with partners including law enforcement to limit access, share 
research and evidence and lessons learnt including responding to and managing suppliers we will 
deliver on the actions outlined in the Strategy. 
ACC 
the monitoring of on line pro-suicide forums. However, this is resource-intensive and at present there 
is no national agency charged with this responsibility and in any event we believe there is no legal 
basis for a police force to pursue such an initiative. Such monitoring would involve a large number of 
forums, many of which do not facilitate crime, raising significant lawful data processing issues, 
including whether it amounts to a Bulk Personal Dataset or would require a Directed Surveillance 
Authority and a potential disproportionate interference under Article 8. In fact the National Crime 
Agency (NCA) have stated that this type of activity is not consistent with the NCA’s overall mission of 
combatting serious and organised crime or the significant ambitions of the NCA Strategy in particular 
in respect of degrading the most harmful organised crime groups. There is also a lack of fit with the 
Strategic Priorities set for the NCA by the Home Secretary.  

 has engaged with various Law Enforcement partners in UK Law Enforcement regarding 

OFCOM is the regulator of the new Online Safety Act with responsibility to make online 

services safer for the people who use them. Services that fall under their remit will have to follow 
certain rules including protecting users from illegal content and activity online as well as protecting 
children from harmful content. This includes encouraging self harm and/or suicide. The Act covers 
over 130 ‘priority offences’ with main duties in regards to the Act relating to illegal content for services 
to assess risk of harm arising from or activity on the service taking proportionate steps to manage and 
mitigate risk. This includes preventing users from encountering content amounting to one of the 
offences and search services minimising risk of users encountering content amounting to an offence. 
Services also have duties to swiftly take down certain types of non priority legal content. The Act 
places new legal requirements on providers of the following three types of internet search; services 
that allow ‘user to user’ interactions or ‘user generated content’, search services and providers of 
pornographic content. The duties in the Act apply to services with links to the UK regardless of where 
in the world they are based. The Act grants OFCOM a range of enforcement powers and requires 
them to publish guidance on how they will exercise them. In January 2024 they launched the first of 
four consultations with stakeholders on putting into effect illegal content duties and enforcement 
powers under the Act.  

Recognising the importance of informed responses, the Steering Group have disseminated 

briefing materials to all NPCC force and regional suicide prevention leads. In June 2023, ACC 
wrote to all Chief Constables, highlighting the need for preparedness in addressing sodium nitrite 
related challenges. The Steering Group actively participates in cross-government efforts to address 
this suicide method. Our focus is on reducing access to sodium nitrate and limiting public awareness 
of its use in suicides, consistent with national strategies. While the Steering Group plays a crucial role 
in suicide prevention strategy, it is important to note that the quality and extent of crime investigation, 
including the investigation of the death in question, are matters for individual Chief Constables. As 

2 

 
 
 
 
 
 
 
 OFFICIAL

’s role does not extend to directing specific actions in investigations conducted by 

such, ACC 
the Metropolitan Police or any other force. We are committed to preventing avoidable deaths and 
providing support to those at risk, continuously exploring innovative strategies to enhance our 
prevention efforts. 

ACC 

 believes that where necessary, proportionate and reasonable steps within the law 

are being taken to identify imports of Sodium Nitrate and Nitrite and other emerging novel suicide 
methods and that Police forces and health professionals continue to provide an appropriate response 
and support to those identified at risk. The NPCC remains committed to working with the Home Office 
and DHSC, who lead cross-government work on Suicide Prevention, to explore all options to prevent 
avoidable deaths and hope that responsible and appropriate reporting is supported and adhered to at 
all times with supportive and appropriate links to organisations that can, are able and do support 
those who may find themselves in crisis at any time https://www.samaritans.org/about-
samaritans/media-guidelines/  

Regards,   

Inspector 
(on behalf of ACC 

)’’ 

3

From 

Parliamentary Under Secretary of State 
Department of Health & Social Care 

39 Victoria Street 
London 
SW1H 0EU 

8 May 2024 

Our Ref: 

Mr Paul Rogers  
HM Assistant Coroner 
Inner West London Coroner’s Court  
33 Tachbrook Street 
London  
SW1P 2ED 

Dear Mr Rogers,  

Thank you for your correspondence of 19 December to the Secretary of State for Health 
and Social Care about the death of Chloe Elizabeth MacDermott. I am replying as Minister 
with responsibility for mental health and suicide prevention, and I thank you for the 
additional time provided to the department to respond.    

Firstly, I would like to say how deeply saddened I was to read of the tragic circumstances of 
Mrs MacDermott’s death, and I offer my sincere condolences to her family and loved ones. 
The circumstances your report describes are very concerning and I am grateful to you for 
bringing these matters to my attention. 

I would like to assure you that the Government remains concerned about the prevalence of 
suicide and self-harm content online. The Government is taking a leading role in tackling 
methods of suicide, collaborating with partners across the world in policy, law enforcement 
and society more broadly to limit access, and share research, evidence and lessons 
learned. There are multiple actions in place to reduce and restrict access to this website, 
and others like it. This will include seeking to tackle at source the suppliers of harmful 
substances for the purposes of suicide.  

The Department leads a cross-government and cross-sector group established specifically 
to identify and proactively tackle emerging methods of suicide. This involves close working 
across government and with others to ensure we are taking rapid, targeted action to 
address these methods- and has been prioritising tackling sodium nitrite. Through this 
group’s close working, there are currently over 30 live actions and interventions that 
collectively are:   

• 

• 

reducing public access to methods, including by reducing the sale and importation of 
methods where appropriate; 
reducing references to, and limiting awareness of, emerging methods, including by 
tackling online content and working with the media to ensure responsible reporting; 
and 

•  monitoring data and trends to inform rapid and targeted responses, improving the 
data we collect, and how that information is best shared to inform responses. 

 
 
 
 
 
 
 
 
 
  
 
 The suicide prevention strategy for England published on 11 September 2023,  
identifies promoting online safety and tackling methods of suicide as priority areas 
for action. The Department has also launched a national near real time suspected 
suicide surveillance system in November 2023 to improve the timely reporting and 
action to prevent suicides. This will support the rollout of a new national alert system 
to notify schools, universities, and charities of emerging methods of suicide and 
risks.  

To address your concerns about unfettered access to harmful content and restricting such 
content, we have made enquiries with the Department for Science, Innovation and 
Technology (DSIT). Under the Online Safety Act 2023 (OSA) all in-scope services such as 
user-to-user platforms and Search services will have new duties to prevent users being 
harmed by illegal content that they encounter via their services. User-to-user platforms will 
also need to take steps to reduce risks that their services are used to perpetrate offences. 
These duties extend to the unlawful supply, or offer to supply, of controlled drugs. Platforms 
and Search services will need to take steps to prevent users encountering illegal sale of 
drugs content via their services. Platforms will need to remove this content when it does 
appear. You may wish to contact the DSIT for more detailed information regarding how the 
Online Safety Act will address illegal and harmful self-harm and suicide content. 

It is not clear from your report the form of the substance or product used by the deceased. 
My department has written to you separately (e-mail of 28 March) to clarify this point and 
will be happy to look again if this information is supplied. But we made some enquiries with 
the Food standards Agency (FSA) which may be of interest to you.  

The regulations that cover the use of nitrates and nitrites in food sits with the FSA in 
England, Wales and Northern Ireland, and in Scotland responsibility rests with Food 
Standards Scotland (FSS). Nitrates/nitrites are and remain important preservatives and are 
one of many ways that a food business can choose to hinder the growth of harmful micro-
organisms. All food additives including nitrates and nitrites (E 249 – E 252) are subject to 
assimilated legislation, Regulation (EC) No. 1333/2008, on food additives, which 
establishes conditions of use for all food additives authorised in Great Britain. The group of 
nitrates/nitrites regulated include E 251 – Sodium Nitrate. The legislation sets out the 
acceptable conditions of use, the foods in which they may be used and where necessary, 
maximum permitted levels. The FSA website provides information on permitted food 
additives for the public and food business operators. 

Nitrate is commonly found in curing salt (also known as ‘pink salt’ or the branded product 
called ‘Prague powder’ which is a mixture of table salt and sodium nitrite; or table salt, 
sodium nitrate and sodium nitrite) which can be sold on-line for home curing and is often 
sold as a component of DIY sets such as ‘make your own ham, bacon and chorizo’ kits. 
However, there are mandatory labelling provisions in assimilated Regulation (EU) No 
1169/2011, which requires foods, including food additives, to be labelled with conditions for 
use and instructions for use, including any required dilution factors. The DIY kits come with 
instructions on safe use. When sold to the final consumer such kits must be labelled as ‘for 
food use’ and can only be sold in a mixture with salt or a salt substitute. If a food does not 
bear the appropriate safety labelling, then under the assimilated General Food Safety 
legislation (EC) No 178/2002, such omission would mean the product cannot lawfully be 

 
 
 
 
 
 
 
 
 
 placed on the market. If found to be non-compliant with the legislation the product can be 
recalled and there can be prosecution for placing unsafe food on the market.   

I note that the Home Office is a recipient of this report and for your concerns around border 
and/or custom controls, I refer you to the Border Agency as the lead on preventing the 
importation of drugs at UK borders. A priority of the Government’s 10-year drug strategy is 
to “break drug supply chains.” The Government made further commitments in its Serious 
and Organised Crime Strategy 2023-2028, including to deliver an “end-to-end plan to tackle 
drugs supply”, which includes strengthening border controls on illicit commodities. The 
National Crime Agency (NCA), which leads and coordinates the UK law enforcement 
response to serious and organised crime and may also be able to provide further 
information on this topic. 

I hope this response is helpful. Thank you for bringing these important concerns to my 
attention. 

Yours sincerely,

Secretary of State for Science, Innovation 
and Technology 
100 Parliament Street 
London SW1A 2BQ 

www.gov.uk/dsit 

21 February 2024 

Our Ref: 

Mr Paul Rogers  
HM Assistant Coroner Inner West London 

Dear Mr Rogers, 

Thank you for your correspondence of 3 January to the Secretary of State for Culture, Media 
and Sport, 
, regarding your Regulation 28: Report to Prevent 
Future Deaths regarding the tragic death of Chloe Elizabeth MacDermott. Your 
correspondence was passed to the Department for Science, Innovation and Technology due to 
our responsibility for points raised in the report, including the Online Safety Act (the act). 

First and foremost, I would like to extend my deepest condolences to the family and friends of 
Chloe. The government recognises that the internet can, in some cases, be used to access 
appalling content with devastating consequences. As you may know, the act received Royal 
Assent in October last year. This legislation will force companies to take more accountability for 
the safety of their users. I will address matters (2)-(8) from the report in my response, as per 
my department's remit and having engaged with the Ministry of Justice on the areas which fall 
into their remit. 

As you will be aware, under section 2(1) of the Suicide Act 1961 (as amended by section 59 of 
the Coroners and Justice Act 2009) it is an offence for a person to do an act capable of 
encouraging or assisting the suicide or attempted suicide of another person, with the intention 
that their act will encourage or assist the other person to commit or attempt to commit suicide. 
The person committing the offence need not know the other person or even be able to identify 
them. An offence may be committed whether or not a suicide or attempted suicide takes place. 
Section 2(1) of the Suicide Act 1961 applies when the act of encouraging or assisting suicide is 
committed in England or Wales. Forums causing concern, such as the one mentioned in your 
report, are often hosted outside the UK, which may prevent successful prosecution due to 
issues related to jurisdiction and enforcement. Under common law rules in cross-border cases, 
however, the courts of England and Wales will have jurisdiction over an act done outside the 
jurisdiction if it has a "substantial connection" with the jurisdiction (unless it could be argued 
that the conduct ought to be dealt with by the courts of another country). Whether or not this 
test is met in any individual case will be a matter for the Court. 

Providing information about or discussing the issue of suicide, where there is no intention to 
encourage or assist suicide, is not an offence. There can, of course, be a fine line between 
simply providing information about suicide, sharing content that unintentionally has the effect 
on an individual of encouraging them to take their life, and someone intentionally encouraging 
a person to take their own life. There is a difficult balance to be struck between reducing the 
availability of harmful material and allowing the positive contribution that the internet can 
provide for those seeking help and support to overcome suicidal feelings. The 1961 criminal 
offence has a high threshold to avoid criminalising people who are expressing suicidal feelings 
and those offering them support. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I will now turn to the provisions in the act, and how the regulatory framework will address online 
suicide content, such as the type of content that Chloe may have accessed before her death. 
The act's illegal safety duties will apply to all in-scope 'user-to-user' services which allow users 
to post content online, or to interact with each other - including online forums. This means that 
once these duties are in force, they will be required to have systems and processes in place to 
proactively prevent users from encountering priority illegal content via their service and to 
minimise the length of time for which such content is present. The priority offences are set out 
in schedules 5, 6 and 7 and includes content that amounts to an offence under the Suicide Act 
1961. This will help to protect all users - children and adults - from encountering this appalling 
content. The act also creates a new offence of intentionally encouraging or assisting serious 
self-harm. This offence applies to acts committed outside the UK if the act is committed by a 
person habitually resident in the UK. In other circumstances, the common law rules on 
jurisdiction will apply as with offences under the Suicide Act 1961. All in-scope user-to-user 
services will be required to put in place systems and processes that allow them to rapidly 
remove content where it reaches the threshold of this offence. 

Search services will also have targeted duties that focus on mitigating and minimising the risk 
of users encountering illegal search content, including illegal suicide and self-harm search 
content. This includes, under section27(4), a requirement for search services to take or use, 
where proportionate, measures to be applied to the services' user support measures. The 
regulator now responsible for online safety, Ofcom, will recommend measures that search 
services can put in place to achieve these objectives. These could include removing results for 
sites that are known to host illegal suicide and self-harm content such as the forum you 
reference in your report, as well as signposting users that search for suicide methods away 
from this material and towards sources of support, which you highlight as a measure that was 
non-existent on the site Chloe had accessed. These duties will play a key role in reducing the 
volume of user traffic directed to websites with illegal suicide and self-harm content, reducing 
the ease at which users can find these kinds of horrifying sites and content. 

It is especially important that children are protected from encountering content that may 
encourage them to self-harm or take their life. The act therefore places additional requirements 
on relevant in-scope online services to shield their child users from content that is legal, but 
nonetheless presents significant harm to them. All in-scope user-to-user services that are likely 
to be accessed by children will need to put in place systems and processes to prevent children 
of all ages from encountering legal content that encourages, promotes, or provides instructions 
for suicide or deliberate self-injury. Ofcom will recommend the measures companies can put in 
place to fulfil this objective. Many services prohibit this kind of content on their service, but 
where services actively permit it the act places more robust requirements on them - in 
acknowledgement of the serious risk this content poses to children. User-to-user services that 
allow these types of content are required to put in place systems and processes to prevent 
children from accessing this damaging content, including the use of highly effective age 
verification or age estimation solutions. 

The government is acutely aware that users may decide to use virtual private networks (VPNs) 
to bypass protections, which is an issue you have raised. Under the act, in scope services will 
need to consider any risks arising from how their service is used as part of their illegal content 
and child safety risk assessment duties and then effectively mitigate and manage risks that 
they identify. Service providers may therefore be required to think about how safety measures 
they put in place could be circumvented - including through the use of VPNs - and take steps to 
prevent that or risk being treated as non-compliant. Ofcom is currently running a public 
consultation on its draft 'illegal content duties' codes of practice and details of this are on its 
website: https://www.ofcom.org.uk/consultations-and-statements/category-1/protecting-people-
from-illegal-content-online. 

 
 
 
 
 
 
 
 There will be sites and services that choose not to comply with the act's regulatory framework. 
In these instances, Ofcom has a suite of robust enforcement powers to support its regulatory 
functions. These extend to instances where companies are based overseas but have a 
significant number of UK users or the UK as a target market. Ofcom's powers include the ability 
to apply to the court for business disruption measures. These are court orders that require third 
parties (those who provide an access facility to such services, such as internet service 
providers) to prevent, restrict or deter access to non-compliant services in extreme 
circumstances. 

Every suicide is a tragedy, and it is essential that the vital protections delivered for users by the 
act come into force as soon as possible. My department is working closely with Ofcom to 
ensure that the implementation of the framework is as short as possible and all users, 
especially vulnerable users, get the online protections they so greatly need and deserve. 

Yours sincerely, 

Secretary of State for Science, Innovation and Technology

Belgrave House, 76 Buckingham Palace Road, London SW1W 9TQ, United Kingdom

Google UK Limited

Private & confidential
Mr Paul Rogers
Inner West London Coroners Court
33 Tachbrook Street
London
SW1P 2EP

By post and email:

Dear Paul Rogers,

13 February 2024

Regulation 28 - Prevention of Future Deaths (Chloe Elizabeth MacDermott)

We refer to your Report on the Prevention of Future Deaths dated 19 December 2023 (“the Report”). This
letter serves as a formal response to the queries and points raised within the Report.

We are deeply saddened to hear of the tragic circumstances relating to the death of Chloe Elizabeth
MacDermott. We understand from the Report that prior to her death on 23 May 2021, Ms MacDermott
researched ways to end her life using the internet and internet chat rooms, including a specific site

(“the Site”). The Report highlights that the Site is a forum that permits material to

be exchanged and viewed within chatrooms, including the exchange of information and methods of
suicide. Further concerns are raised in the Report, including the lack of age restrictions on the Site, the
lack of prominent self-help signposting on the Site and the lack of content moderation on the Site. It is
unclear from the Report whether Ms MacDermott used Google Search (or another search engine) to find
the Site; nevertheless, we would like to take this opportunity to set out Search’s approach to keeping
users safe from harmful and illegal suicide and self-harm content.

Google Search serves as an index of information on the open web. When an individual enters a search
query, it uses algorithms to return search results linking to the relevant web pages in the index, ranked
from most to least relevant. Safety is core to how Google develops and operates its services, and we
understand our responsibility to keep users safe, while still ensuring the free flow of information. As with
all of our search ranking systems, we’re continually making improvements to ensure that we’re providing
people with the highest quality information possible, while also not showing people shocking or
potentially harmful results that they are not explicitly seeking.

In relation to suicide and self-harm content, we take a combination of approaches, including (i)
prohibiting policy violative content in Search features; (ii) providing information and resources via hotline
oneboxes; and (iii) providing specialised ranking approaches for suicide and self-harm queries. We set
out more detail on these measures below.

We note that people use Search for suicide-related queries for many different reasons, including looking
for support to manage their thoughts in moments of crisis, or seeking information as to how to support

Registered address: Belgrave House, 76 Buckingham Palace Road, London SW1W 9TQ
Registered in England and Wales with registration number 03977902

 Google UK Limited

Belgrave House, 76 Buckingham Palace Road, London SW1W 9TQ, United Kingdom

loved ones. We recognise how important it is to increase awareness around help-seeking behaviours,
while decreasing risk-taking and reducing stigma. We have therefore developed the measures below
through extensive consultation with both internal and external experts in psychology, mental health, and
related areas. These include not only academics and clinicians, but also practitioners who provide direct
services to vulnerable populations.

We also note that some of these measures have been implemented since May 2021, as we are
continually evolving our processes in response to information, like user behaviour and sensitive content
types, to ensure we are promoting authoritative and trusted content, while demoting content that could
be harmful to users. We also recognise the importance of implementing robust systems and processes
that provide our users with a level of protection that surpasses legal requirements.

Policies and processes relating to suicidal content on Google Search

We are aware of the prevelance of user-to-user pro-suicide forums and the danger they pose. This means
that we adopt a variety of measures to keep users safe from this type of content.

● Where Search receives a valid removal request under UK law, Google will delist the URL from

the search results. The removal process we employ involves taking down URLs that are visible
on Search. Our URL removal process is designed to target specific URLs that appear on our
Search results, rather than implementing a blanket removal for entire domains. This approach
allows us to address individual URLs that may contain unlawfully-published content while
preserving the accessibility of valuable and relevant information on the internet. For the
avoidance of doubt, if Google were to receive a valid removal request relating to a URL
featuring on the Site and it was determined to be illegal under UK law, the URL would be
delisted.

● Content that promotes or glorifies suicide or self-harm can often fall into the category of legal
but harmful, rather than illegal. Our ranking algorithms consistently classify these types of
suicide forums as low quality, meaning that they will not feature highly in search results,
particularly in response to general suicide-related queries. Conversely, higher quality results
and information bars will be promoted (such as links to the Samaritans, NSPCC and other
relevant charities). By integrating links and phone numbers on Search to reputable mental
health organisations, Google Search aims to make it easier for users to seek help and
guidance when they may need it. We note that, as it stands, the Site does not rank highly in
Search for general queries related to self-harm or suicide.

● As a further measure to support both vulnerable users and the organisations they turn to for
help, Google Search has taken proactive steps by working with the Samaritans to implement
“OneBoxes” which display prominently in response to suicide-related queries. These
information boxes are designed to provide users with quick and easy access to authoritative
resources and support for mental health needs, including a 24 hour helpline and links to the
Samaritans’ official website. We also note that when users search specifically for the Site, our
systems will surface this Samaritans OneBox, with a phone number for national hotlines.

● Google Search also enforce content policies on Search features, such as Autocomplete
predictions, to prevent surfacing dangerous content and we design our systems to avoid

Registered address: Belgrave House, 76 Buckingham Palace Road, London SW1W 9TQ
Registered in England and Wales with registration number 03977902

 Google UK Limited

Belgrave House, 76 Buckingham Palace Road, London SW1W 9TQ, United Kingdom

showing violative predictions. We don’t allow content that could directly facilitate serious and
immediate harm to people (such as content that promotes self-harm, or content that provides
instructions on committing suicide).1 This means that Google will not predict a search query
such as “how to commit suicide”. In response to concerns about this Site, Google will also not
predict a search query for the Site or the specific method of suicide mentioned in the Report
(e.g. by predicting “sanctioned suicide” or “suicide sodium nitrate”).

As outlined above, many websites featuring suicide content are not necessarily currently illegal under UK
law, and nor are search engines required by law to delist them. Google strongly supports the objectives
of the Online Safety Act 2023 (“OSA”), which will give the industry regulator, Ofcom, enforcement powers
against user-to-user services (like the Site) where such services do not have sufficient systems and
processes to protect users from illegal content or children from content that is harmful to them. The
regime will also give clarity over circumstances where search engines will be required to minimise users’
access to certain content.

Google remains committed to continually improving services to prevent users from finding and
experiencing harmful content, whilst also providing users with authoritative information on wide ranging
topics.

To the extent that you have any specific queries about Google Search please direct them to Google LLC,
the entity that provides this service on behalf of UK users. Google LLC is a US company incorporated in
Delaware, with its principal place of business at 1600 Amphitheatre Parkway, Mountain View, California,
CA 94043, United States. Otherwise, if we can be of any further assistance on this matter, please do not
hesitate to contact us.

Yours faithfully

Legal Department
Google UK Limited

1 https://support.google.com/websearch/answer/10622781?hl=en

Registered address: Belgrave House, 76 Buckingham Palace Road, London SW1W 9TQ
Registered in England and Wales with registration number 03977902

Classification: HIGHLY SENSITIVE

CONFIDENTIAL

Paul Rogers 
His Majesty’s Assistant Coroner Inner West 
London  
Inner West London Coroner’s Court 
33 Tachbrook Street 
London SW1P 2ED 

Director, Online Safety Strategy Delivery 

Email: 

12 February 2024 

Dear Mr Rogers, 

We write in response to the Regulation 28 report to Prevent Future Deaths, received 19th December 
2023, which was issued to Ofcom following the death of Chloe Macdermott (‘the Report’).  

On behalf of Ofcom, I would like to offer my deepest condolences to Ms Macdermott’s family and 
loved ones. Ensuring that online services, such as those mentioned in the Report, fulfil their duties in 
regard to harmful suicide content is a key priority for Ofcom as we begin to implement the Online 
Safety Act.  

i. 

Response to Regulation 28 report following inquest into the 
death of Chloe Macdermott 

In this response, we set out our proposed actions in relation to the issues raised by the Report, 
where these fall within the scope of the Online Safety regime, and the timetable for these actions. 
These actions are pursuant to the new duties and powers assigned to Ofcom by the Online Safety 
Act 2023 and relate to Ofcom’s plans for implementation of the Act as the UK’s regulator for online 
safety.  

We thank the coroner’s office for bringing our attention to the specific, tragic circumstances 
surrounding Ms Macdermott’s death. Intelligence about the real-world effects of online harms and 
their links to specific services will be crucial as we develop our approach to the Online Safety regime.  

The report outlines a number of detailed matters of concern and our response below highlights the 
steps we are taking to promote compliance with the requirements of the regime across all relevant 
regulated services. 

We are currently in the process of putting in place regulation to implement the Online Safety 
regime. Until the relevant procedural steps outlined below are completed, the duties on regulated 
services are not yet fully in force. Further detail on Ofcom’s planned approach to online safety 
regulation is set out below. Whilst the regime is at this early stage, we are supporting all in scope 
services to be compliant with the provisions of the Act and intend to seek to engage constructively 
with services.  

Ofcom, Riverside House, 2a Southwark Bridge Road, London SE1 9HA 
Switchboard: 0300 123 3000 or 020 7981 3000 
www.ofcom.org.uk  

 
 
 
 
  
 
 
 
 
 Classification: HIGHLY SENSITIVE

Following reports1 of alleged illegal and harmful suicide content on 
contacted the service which subsequently announced via its website that UK users would be 
blocked. As of 31st January 2024, we are aware that the site is accessible by UK users. This is a 
situation which we will continue to monitor.  

, Ofcom 

 The Online Safety Act 2023 

The Online Safety Act 2023 (‘the Act’) received Royal Assent on 26 October 2023 and makes persons 
that operate a wide range of online services legally responsible for keeping people safer online. The 
Act covers certain categories of internet services that have links with the UK including what are 
known as user-to-user services and search services. The Act defines a user-to-user or search service 
as having links to the UK if it meets any one or more of the following criteria: 

•  Has a significant number of UK users; or 
•  Has UK users as one of its target markets; or 
• 

Is capable of being used by UK users, and there are reasonable grounds to believe that there 
is a material risk of significant harm to UK users.  

Any service which meets one more or the above criteria, and which is not exempt2, will be expected 
to comply with the relevant duties under the Act.  

Among other things, the Act: 

•  Appoints Ofcom as the regulator for online safety and confers upon us a number of powers 

and duties (set out in detail below). 

• 

Imposes a number of duties on those regulated services which focus on improving the 
systems and processes online services operate to ensure the safety of their users, rather 
than on the presence of individual pieces of content.  

•  Requires regulated services to assess the risks their services pose to users in relation to 

illegal content and content that is harmful to children and take steps to mitigate and manage 
those risks. 

•  Requires Ofcom to issue a number of regulatory publications to help regulated services 

understand how they can comply with their legal duties.  

•  Requires Ofcom to publish resources to help companies assess, understand and manage 

risk.  

•  Ofcom will also produce Codes of Practice, setting out recommended measures services can 
take to comply with the relevant duties under the Act in order to mitigate the risk of harm. 

As explained further below, the duties on all regulated user-to-user services relating to protecting 
their users from illegal harms will require those services to understand and take steps to manage 
and mitigate the risks of users encountering illegal suicide content3, or their services being used for 
the commission or facilitation of this offence. User-to-user services will also have to swiftly take 
down illegal suicide and illegal self-harm content when it is identified. Where regulated services are 
likely to be accessed by children, they will also have to take steps to prevent child users from 

1 BBC News, ‘“Failure to act” on suicide websites linked to 50 UK deaths’, 24 October 2023 
2 A number of exemptions also apply as set out in Schedule 1 to the Act. See: Vol 1, Section 3 of our Illegal Harms 
Consultation 
3 In other words content that would ‘amount to’ an offence of assisting or encouraging suicide under s.2 of the Suicide Act 
1961 or s. 13 of the Criminal Justice Act (Northern Ireland) 1966. 

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encountering content that encourages, promotes or provides instructions for suicide or deliberate 
self-injury.4  

Ofcom would only have a role in connection with the prevention of supply or marketing of particular 
substances within the UK insofar as this relates to a type of content or activity that would be caught 
under duties in the Online Safety Act. Based on the information available in the report, it is not clear 
that material relating specifically to the supply or marketing of the substance itself would fall in 
scope of the duties under the Act. 

There are also additional duties which apply to certain user-to-user services which will be 
‘categorised’ based on user numbers and functionalities (these services will be known as ‘Category 1 
services’). These duties are designed to make these services more transparent and accountable to 
their users about the steps they take to protect them from harm; and enable adult users to have 
more control over the type of content they encounter, including by having access to tools to reduce 
their potential exposure to suicide and self-harm content. 

A set of separate duties apply to regulated search services. These duties focus on those services 
understanding the risks of harm and focus on services taking steps to minimise the risk of individuals 
encountering illegal suicide and self-harm content and content that encourages, promotes or 
provides instruction for suicide or deliberate self-harm to children in search results. 

Although the Act is now law, there are numerous procedural steps needed for the new regime to be 
fully implemented, and these steps need to be completed before services’ legal duties under the 
regime - and Ofcom’s ability to enforce those duties – come into force. These steps include, for 
example, the completion of public consultations (the first is currently open for illegal harms); 
services understanding and managing the risks of harm to their users; and Parliament approving 
Ofcom’s final Codes of Practices. We explain our plans to implement the regime below. 

In the meantime, we are already encouraging in-scope service providers to take meaningful steps to 
improve safety on their platforms. To this end, we are committed to driving industry improvements 
by engaging with the largest and riskiest services via continuous ‘regulatory supervision.’  

ii.  Ofcom’s implementation of the Online Safety Act 

To coincide with Royal Assent, we set out our approach to implementing the Act on our website – 
this included an implementation road map setting out our key phases of work over the next three 
years as set out above. We set out in summary below our intended plans for implementation, and in 
diagram form in Figure 1. This timeline shows our key milestones and documentation but is not a 
comprehensive guide to everything we will produce over the first three years of the regime. 

4 There are similar duties on regulated search services which focus on those services understanding the risks of harm and 
focus on services taking steps to minimise the risk of individuals encountering illegal content and content that is harmful to 
children in search results. 

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  Figure 1: Ofcom’s timeline for Online Safety implementation

Phase One: The first step in this was the publication of the Consultation: Protecting people from 
illegal harms online  (‘illegal harms consultation’) on 9 November 2023. As part of this consultation, 
we published proposals for Codes of Practice which set out how services can comply with their illegal 
content duties in the Act.5 We also published draft Illegal Content Judgements Guidance on how 
services can identify illegal suicide and illegal self-harm content.  

Phase Two: We also published our Consultation: Guidance for service providers publishing 
pornographic content on 5 December 2023, which includes draft guidance on age assurance and 
other duties for services providing pornographic content. This will be followed by a broader 
consultation on measures to protect children from encountering other harmful content, including 
legal suicide and self-harm content, in Spring 2024.  

Phase Three: From late 2024, we will publish a call for evidence on additional duties on categorised 
services, which includes user empowerment measures that will apply to ‘Category 1’ services, 
followed by a full consultation on proposals in Q1 2025.  

As part of our preparatory work for implementation, we have been actively engaging with a range of 
expert stakeholders including government, law enforcement, and charities such as the Samaritans to 
develop our understanding, expertise and evidence base in relation to suicide and self-harm, and to 
ensure that we are aware of developing areas of risk. We have also been concentrating on growing 
our internal expertise in relation to this complex and important harms area. We will continue our 
programme of engagement with relevant experts as we consult on our initial proposals on how 
services can comply with their duties.  

Phase One 

Ofcom’s illegal harms consultation: assessing risks 

The Act requires Ofcom to produce a register of risks for illegal harms, and guidance to assist 
services in conducting their own risk assessment. Our draft guidance sets out a four-step risk 

5 It is not mandatory for services to implement all measures in our Codes of Practice. However, where Codes of 
Practice are not implemented in full, services are obliged to demonstrate the steps they have taken to achieve 
the same safety outcomes  

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assessment process which we propose as the best way to ensure that a service’s assessments meet 
their obligations. 

We are also consulting on our ’Risk Profiles’, which set out an explanation of factors in service design 
and operation that increase risk of harm. Services will be required to take account of our Risk 
Profiles when conducting their risk assessments. The information contained in the Risk Profiles is 
sourced from Ofcom’s own Register of Risk.  

For illegal suicide and self-harm content, we set out risk factors relating to: 

• 

service type; 

•  user base; 

• 

• 

functionalities of the service; and 

recommender systems. 

We are using the consultation process to help us finalise this work.  

Ofcom’s illegal harms consultation: Codes of Practice 

The Act requires Ofcom to produce Codes of Practice setting out the measures that in-scope services 
may take to comply with their duties under the Act.6 The Codes will recommend proportionate 
systems and processes across a number of areas, including: moderation, governance, and user 
complaints. While services are not required to implement all measures in our Codes of Practice, in 
the event that they choose not to take the steps recommended, they will need to be able to explain 
how their chosen approach allows them to be compliant with their legal duties.  

We published our illegal content Codes of Practice in draft form alongside our illegal harms 
consultation.7 The proposed measures in our Codes of Practice would require services to, among 
other things: 

•  have a named person, who is accountable to the most senior governance body, for 
compliance with illegal content safety duties, and reporting and complaints duties;  

•  have in place effective and easy-to-find content reporting and complaint mechanisms, so 
that users that encounter illegal content (including illegal suicide and, if the offence is 
brought into force, self-harm content) can report it and see action taken;  

• 

• 

• 

in the case of medium or high-risk services that use algorithms to recommend content to 
users, measure the risk that changes to algorithms increase the chance of users' exposure to 
illegal content (including illegal suicide and self-harm content); 

in the case of user-to-user services: have in place content moderation systems or processes 
that are designed to take down known illegal content (including illegal suicide and self-harm 
content) swiftly; and 

in the case of search services: have systems and processes in place that are designed so that 
search content that is illegal content is deprioritised or deindexed for UK users. 

In addition, our draft Codes of Practice include a proposal that search services should provide crisis 
prevention information in response to search requests that contain general queries regarding suicide 

6 Section 41 of the Act 
7 Ofcom, ‘Consultation: Protecting people from illegal harm online’, November 2023. See: Volume 4: How to mitigate the 
risk of illegal harms – the illegal Content Codes of Practice, Annex 7: Illegal Content Codes of Practice for user-to-user 
services and Annex 8: Illegal Content Codes of Practice for search services. 

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and queries seeking specific, practical or instructive information regarding suicide methods. This 
information should include a helpline and links to freely available supportive information provided 
by a reputable mental health or suicide prevention organisation. It should also be prominently 
displayed to users in the search results.  

Ofcom’s illegal harms consultation: Illegal Content Judgements Guidance 

Our illegal harms consultation includes a draft version of Ofcom’s Illegal Content Judgements 
Guidance.8 This document provides guidance to in-scope services on how they may identify illegal 
content (content which may be reasonably inferred to amount to a relevant offence) including under 
Section 2 of the Suicide Act 1961.  

In our draft guidance, we note the intentional act of encouraging or assisting the suicide (or 
attempted suicide) of another person is an offence and have proposed that, in certain contexts, the 
provision of specific, practical or instructive information on suicide methods – for example about 
how to take one’s life, and content inducing someone to enter into a ‘suicide pact’, are likely to be 
able to be inferred to be illegal content. Our draft guidance therefore suggests that content of this 
type should be removed from services in order for providers to be compliant with their illegal 
content safety duties.  

We are seeking further evidence and feedback from stakeholders on these proposals as part of our 
consultation.  

After Ofcom’s illegal harms consultation and statement 

Once we have completed our illegal harms consultation, we are required to publish a statement 
setting out our response to issues raised by stakeholders, and our final policy decisions.  

The Online Safety Act requires Ofcom to submit our Codes of Practice on illegal harms to the 
Secretary of State and to publish associated guidance within 18 months of Royal Assent. Once we 
issue our statement, services will have three months to undertake their illegal content risk 
assessments. At this point we will also submit the Codes of Practice to the Secretary of State, which, 
subject to their approval, are to be laid in Parliament for 40 days.  

Following approval by Parliament, the Codes will come into force 21 days after they have been 
issued. At this time the illegal harms safety duties become enforceable, and we can begin 
investigations and – following the conclusion of those – impose sanctions if we find that services are 
not compliant with these duties.  

Phase Two: 

Phase Two will focus on child safety and include a consultation on protecting children, to be 
published in Spring of 2024. The consultation will include our proposals for: 

•  Draft guidance for services on carrying out their Children’s Access Assessments 
•  Ofcom’s analysis of the causes and impacts of harms to children 
•  Draft guidance on carrying out Children’s Risk Assessments 
•  Draft Codes of Practice setting out recommended measures to protect children 

online.  

8 Ofcom, ‘Consultation: Protecting people from illegal harm online’, November 2023. See: Volume 5: How to judge whether 
content is illegal or not? (Illegal Content Judgements Guidance) and Annex 10: Online Safety Guidance on Judgement for 
Illegal Content. 

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The Act places requirements on services that are likely to be accessed by children to protect children 
from content which is legal but harmful to them. Services which are required to comply with the 
safety duties protecting children will be under a duty to operate a service using proportionate 
systems and processed designed to prevent children of any age from encountering ‘primary priority 
content that is harmful to children’. Content which ‘encourages, promotes or provides instructions 
for suicide’ or ‘for an act of deliberate self-injury’ has been designated as ‘primary priority content’ 
under the Act.  

Regulated services will have three months to carry out Children’s Access Assessments after we 
publish our final Guidance. If they conclude that they are likely to be accessed by children, then they 
will have to carry out Children’s Risk Assessments. We intend to publish our final Guidance on 
Children’s Access Assessments in early 2025. Our main statement on the Children’s Safety Duties will 
follow in Spring 2025. This will allow services to complete their initial Children’s Access Assessments 
and determine whether they need to comply with the children’s safety duties, before the 
requirement to carry out Children’s Risk Assessments comes into force.  

At that point (Spring 2025), relevant services will have three months to carry out a Children’s Risk 
Assessment. At the same time, we will submit the children’s Codes of Practice to the Secretary of 
State. Subject to the Secretary of State’s approval, they will then be laid in Parliament for 40 days. 
Following approval by Parliament, the codes will come into force 21 days after they have been 
issued.  

At this time the children’s safety duties become enforceable, and we can begin investigations and 
impose sanctions for non-compliance. Assuming Parliament immediately approves the codes, we 
expect the duties to become enforceable in Summer 2025.  

Phase Three: 

Phase Three of online safety focuses on transparency, user empowerment, and other duties which 
will apply to Category 1 services.9 

The user empowerment duties in particular will include a duty to include, to the extent that it is 
proportionate to do so, features which adult users may use or apply if they wish to increase their 
control over certain kinds of content including content which encourages, promotes or provides 
instructions for suicide or an act of deliberate self-injury. We plan to issue a Call for Evidence 
regarding our approach to phase three in early 2024.  

Regulation of Video Sharing Platforms 

In addition to our preparation for the implementation of the online safety regime, Ofcom has also 
been responsible for regulating UK-established video sharing platforms (VSPs) since November 2020. 
The scope of the VSP regime is much narrower than that of the Act, applying only to services that 
meet the definition of a VSP under Part 4B of the Communications Act 2003 and have the required 
connection with the UK10 and to protecting users from material included in videos only. We include a 
brief summary of the main provisions of the VSP regime which are potentially relevant to the 
broader points covered in the report. 

9 ‘Category 1’ refers to certain user-to-user services categorised based on user numbers and functionalities. Services in this 
category are subject to additional duties related to transparency, user empowerment and protection of democratic and 
journalistic content. ‘Category 1 threshold conditions’ are set the Secretary of State, with advice provided by Ofcom. 
Ofcom will then be responsible for designating services into categories according to these thresholds. 
10 See section 368S of the Communications Act 2003. A full list of notified services may be found on the Ofcom website: 
Notified video-sharing platforms - Ofcom; they include, among others, TikTok, Twitch and Snap 

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Under the VSP Framework, VSP providers are required to take safety measures as are appropriate to 
protect children (under 18s) from videos containing ‘restricted material’. Importantly, they must also 
ensure that the measures they take are implemented effectively. ‘Restricted material’ includes 
material which might impair the physical, mental, or moral development of under 18s. The relevant 
legislation does not specify particular examples of such material. However, in our guidance for 
providers on measures to protect users, we state that VSPs should consider a range of harms, 
including self-injurious content which may cause physical harms, such as material promoting eating 
disorders, self-harm and suicide. It is for each VSP provider to decide what safety measures to take 
that are appropriate and proportionate for protecting children on their service from videos 
containing potentially harmful material. Where we have concerns about the measures a platform 
has in place, we will consider taking further action to push improved outcomes for children. This may 
include, where appropriate, targeted supervision or the use of enforcement powers. Our learnings 
under the VSP regime will help us prepare for the broader online safety regime. 

iii.  Conclusion 

The death of Ms Macdermott highlights the tragic impact that suicide and self-harm content can 
have. Ofcom is committed to addressing the risk of harm from such content effectively and 
proportionately. 

Government and Parliament have signalled the importance of tackling such content by designating 
illegal suicide content as a priority offence and legal suicide content as primary priority content that 
is harmful to children, and our strategic priorities reflect this. As we have set out in our approach to 
implementing the Online Safety Act, once the regime is in force we expect change.  

Specifically, we anticipate implementation of the Act will ensure people in the UK are safer 
online by delivering four outcomes:  

• 

stronger safety governance in online firms;  

•  online services designed and operated with safety in mind; 

• 

• 

choice for users so they can have meaningful control over their online experiences; and  

transparency regarding the safety measures services use, and the action Ofcom is taking to 
improve them, in order to build trust. 

We have set out that we will expect all in-scope services to have appropriate trust and safety 
measures tackling the full range of harms listed in the Act. In particular, we want to see wider 
deployment and improvements in services’ measures to address areas which pose the greatest risk 
to people, including illegal and harmful suicide content, to protect UK users, especially children.  

We are committed to working with industry to ensure compliance with these duties, and to this end 
our draft illegal harms Codes of Practice include specific measures which we propose would allow 
services to meet their duties in an effective and proportionate manner. We will ensure that through 
consulting on our proposals we seek input and engagement with external experts. We will also work 
directly with services to promote compliance, including – where appropriate – through targeted 
supervision.  

Where we identify non-compliance, we will not hesitate to take enforcement action where 
appropriate to protect users from harm. We will have the powers to require non-compliant service 

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providers to take remedial action and to impose financial penalties where necessary, as well as 
powers to seek business disruption measures in serious cases.11 

Evidence included in reports from coroners and other experts will play an important role in our 
policy proposals and response as we implement the regime, and we will of course take the evidence 
in your report into account as we continue our policy development. We hope that this response 
provides helpful information about the significant steps Ofcom is taking as we continue to work 
through the implementation of the Act. 

If further information or clarification is required, we would be happy to provide this. 

Yours sincerely, 

Online Safety Strategy Delivery Director 

11 Once the regime is fully operational, in serious cases of non-compliance, we can seek a court order imposing ‘business 
disruption measures’ which require third parties to withdraw services from, or block access to, regulated services. This 
could mean, for example, requiring a payment services or advertising provider to withdraw their business from the non-
compliant regulated service, or requiring an internet service provider to limit access to a non-compliant regulated service. 

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