Prevention of Future Deaths reports · 2024

Guy Scotchford

Regulation 28 report to prevent future deaths, reference 2024-0047, written 31 Jan 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report31 Jan 2024
Reference2024-0047
DeceasedGuy Scotchford
CoronerEmma Hillson
Coroner areaCornwall and the Isles of Scilly
CategorySuicide (from 2015)
Sourcejudiciary.uk record · original PDF
Responses published2

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

Information Classification: CONTROLLED 
Information Classification: CONTROLLED 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

National Crime Agency 
Department for Science, Innovation & Technology 

1  CORONER 

I am Ms Emma Hillson, Assistant Coroner for the coroner area of 
Cornwall and the Isles of Scilly. 

2  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. 

3 

INVESTIGATION and INQUEST 

On 7th July 2023, I commenced an investigation into the death of Guy 
Douglas Scotchford.  The investigation concluded at the end of the 
inquest on 30th January 2024.  

I recorded the cause of death as 

1a) Asphyxiation  

My conclusion as to the death was as follows: 

Suicide 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Information Classification: CONTROLLED 
Information Classification: CONTROLLED 

4  CIRCUMSTANCES OF THE DEATH 

Guy Scotchford had a long history of mental health problems with 
chronic suicidal ideation and believed he was suffering from a condition 
called Mast Cell Activation Syndrome, something he had researched 
extensively. This impacted on his day-to-day health and well 
being. He had a complex past medical history to include depression, 

 addiction and chronic multi system, medically 

unexplained symptoms of unclear cause. There had not been a formal 
diagnosis of Mast Cell Activation Syndrome as there 
was minimal evidence to reach this but he was under specialist care 
provided by the Clinical Immunology Department at Derriford Hospital 
who were providing valuable advice and guidance to manage his 
symptoms. Guy had previously disclosed to his sister, GP and Mental 
Health Services that he had researched ways to end his life and at one 
stage stated he had a plan in place but that he did not intend to act on 
those plans. He had some contact with mental health services and 
engaged in 3 intervention sessions with Wellbeing Coaches in October 
2022 following which he reported feeling better. His final contact with 
the Mental Health Connect team was on 15th May 2023 when he 
reported ongoing chronic suicidal ideation. He agreed to contact with 
his GP and a safety plan was discussed. A review was held with his GP 
on 31st May 2023 at which time his physical and mental health was 
discussed at length. There was no change in his chronic suicidal 
thoughts, and he was keen to explore treatment and support for his 
condition. He declined any referral for further mental health or 
psychology services at that time. 

Guy contacted his sister on the telephone in the early hours of 1st July 
2023 and his opening comment was that he loved her. She stated that 
she would call him later. On attempting to contact him later that 
morning she was unable to get a response and raised a concern for 
welfare.  Police officers attended his home address and he was found 
deceased in the bath. His death was confirmed at 15:24 on 1 July 
2023. His death was due to Asphyxiation. 

Police Officers at the scene located a printed 60-page document at his 
home address titled “
printed from a website - 

” which had been 

.  

confirmed that this company received and delivered an order and they 
also provided a copy invoice dated 28/04/2022. 

. Police enquiries 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Information Classification: CONTROLLED 
Information Classification: CONTROLLED 

5  CORONER’S CONCERNS  

During the course of the investigation, the evidence has 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.   

 is still active and from 

It was clear from the evidence of the investigating officer that the 
website (
this website a 
can be downloaded.  This document gives a direct link to 
a company from which 
delivered. The police investigation determined that this 
named company did receive and supply that order. The downloaded 
document provides step by step instruction on how to end 
your life with specific advice and direction on the use of certain 
equipment. 

 can be purchased in the UK and home 

" 

The investigating officer made a recent internet search of this website 
which states that it provides practical DIY information to enable readers 
to take control over their own life and death. This website is available to 
anyone to access online. 

6  ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I 
believe your organisation have the power to take such action.  

7  YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the 
date of this report, namely by 27 March 2024.  I, the coroner, may 
extend the period. 

Your response must contain details of action taken or proposed to be 
taken, setting out the timetable for action. Otherwise, you must explain 
why no action is proposed. 

8  COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the 
following Interested Persons: 

Mr Guy Scotchford’s family. 

I am also under a duty to send the Chief Coroner a copy of your 
response and all interested person who in my opinion should receive it.  

3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Information Classification: CONTROLLED 
Information Classification: CONTROLLED 

The Chief Coroner may publish either or both in a complete or redacted 
or summary form. He may send a copy of this report to any person who 
he believes may find it useful or of interest. You may make 
representations to me, the coroner, at the time of your response, about 
the release or the publication of your response by the Chief Coroner. 

9  31 January 2024 

Signature 

Emma Hillson 
Assistant Coroner for Cornwall and Isles of Scilly                                            

4

Responses

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

4 September 2025 

Dear Ms Hillson,   

I want to thank you for the opportunity to respond to this Report to Prevent Future Deaths, regarding the 
death of Guy Douglas Scotchford. I was deeply saddened to read about the circumstances surrounding 
Guy's tragic death and would like to extend my deepest condolences to his family and friends for their 
loss.     

As the Secretary of State for Science, Innovation and Technology, I am responsible for the Online 
Safety Act (the ‘Act’) which received Royal Assent in 2023. The Act lays the foundation for strong 
protections against illegal content for all users and harmful material for children. The government is 
committed to working with Ofcom, the independent regulator, to ensure the Act is implemented quickly 
and effectively. The new laws apply to search services and all companies that allow users to post 
content online or to interact with each other (referred to as user-to-user services in the Act). This 
includes a broad range of websites, apps and other services, including social media services, consumer 
cloud storage sites, video sharing platforms, online forums, dating services, online instant messaging 
services and online marketplaces where they allow (regulated) user-generated content, for example 
images or content descriptions uploaded by users.     

Under the Act, all in-scope services, regardless of their size, must have proportionate systems and 
processes to prevent all users from encountering priority illegal content. Under the Act, intentionally 
encouraging suicide and certain drug-related offences are priority offences and content that amounts to 
those offences is deemed ‘priority illegal content’. Priority offences reflect the most serious and 
prevalent illegal content and activity, against which companies must take proactive measures, as well 
as ensuring their services are not used to facilitate or commit a priority offence. These duties came into 
effect in March 2025, and within the first month Ofcom had already launched several enforcement 
programmes against companies failing to comply with these duties, including a pro-suicide forum. On 1 
July, this forum decided to voluntarily restrict access to UK users due to the legal risks associated with 
its duties under the Act. The Act also introduced a new communications offence of intentionally 
encouraging or assisting serious self-harm, which was commenced on 31 January 2024.    

Regulated suicide content is illegal under the Online Safety Act where it amounts to an offence under 
the Suicide Act 1961 (which is the responsibility of the Ministry of Justice). 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 suicide or an attempt at 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.    

 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
   
   
   
   
   
 Under the Interpretation Act 1978 a "person" committing an offence "includes a body of persons 
corporate or unincorporate" unless the relevant provision says or implies otherwise. As with other 
offences, the offence under section 2(1) of the Suicide Act is capable of being committed by a company 
though. However, simply making available, or facilitating the provision of, resources which provide 
information detailing methods of suicide, where there is no intention to encourage or assist suicide, is 
not an offence under the Suicide Act. The criminal offence has a high threshold to avoid criminalising 
people who are expressing suicidal feelings and those offering them support, by for example, sharing 
their own experiences.   

Whether a prosecution for encouraging or assisting suicide can be brought is a matter for the Crown 
Prosecution Service following a police investigation. The CPS policy on assisted suicide1 sets out the 
factors which prosecutors in England and Wales will consider, in addition to those already outlined in 
the Code for Crown Prosecutors, when deciding whether it is in the public interest to prosecute in cases 
of encouraging or assisting suicide.    

The strongest protections in the Online Safety Act are for children, and the legislation provides them 
with additional protections from harmful content which does not reach the criminal threshold. Under the 
Act, where a user-to-user service is likely to be accessed by children, they must put in place measures 
to prevent children of all ages from encountering legal content that encourages, promotes or provides 
instructions for suicide or self-harm. The measures must include the use of age assurance. These 
duties came into effect on 25 July.   

We know that users may find online suicide content via search services. Under the Act, search services 
have targeted duties that focus on minimising the risk of all users encountering illegal suicide and self-
harm search content, and children from encountering legal content which encourages or provide 
instructions for suicide or self-harm. In practice, this could look like removing results for sites that are 
known to host illegal suicide and self-harm content. These duties also include a requirement to take or 
use, where proportionate, user support measures, for example, signposting users towards sources of 
support. Combined, these duties are expected to play a key role in reducing the volume of user traffic 
directed to websites with illegal suicide and self-harm content, reducing the ease with which users can 
find these kinds of sites and content.   

In your report, you raise concern that ‘
of the public. I would firstly like to clarify that under the child safety duties, regulated search services 
must minimise the risk of children encountering (in search results or directly by clicking on them) 
content which encourages or provides instructions for suicide or self-harm, even where it is legal. This 
would involve such content on an online marketplace, and if such search results included content – 
related to a book – which itself encouraged or provided instructions for suicide, or a search result led 
directly to a digital copy of a book which did so, the risk of children encountering this content would 
have to be minimised by the search service.    

’ is still available online to members 

As previously explained, the Online Safety Act does not prevent adult users from accessing legal 
suicide and self-harm content. In some cases, such content may be trying to provide support to those in 
need and this is therefore a complicated area to regulate. To be clear, I am not saying that ‘

’ is such a book.   

The issue therefore is whether the authors or distributors of ‘
books are committing an offence. However, the enforcement of existing offences is not for the 
government, but for the police and the Crown Prosecution Service and it is ultimately for the courts to 
decide if an offence has been committed. As you are aware, relevant criminal offences have a high 
threshold to avoid criminalising people who are expressing suicidal feelings and those offering them 

 or similar 

 
 
 
   
   
   
   
   
   
 support, by for example, sharing their own experiences.  As noted above, offences under the Suicide 
Act 1961 and their thresholds are under the remit of the Ministry of Justice.   

The government is committed to delivering a renewed drive to tackle the number of lives lost to suicide. 
Cross-government action is key in achieving this, and coordinated action is taking place across 
government 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 of 
dangerous methods.    

As leaders of the Suicide Prevention Strategy, officials from the Department for Health & Social Care 
(DHSC) lead a Concerning Methods Working Group to raise awareness of and tackle access to 
emerging methods of suicide. Deaths using nitrogen are monitored routinely as part of this. The working 
group involves representatives from the voluntary community and social enterprise sector, police, 
academics and the NHS, as well as government departments including Department of Science, 
Innovation and Technology. DSIT officials will raise the concerns in your letter around Nitrogen with this 
group and suggest that engagement with UK sellers is undertaken to raise awareness of and minimise 
the risk of harm to individuals.     

I would like to thank you again for drawing this to my attention and I hope that this response is useful in 
setting out where the Online Safety Act will offer significant new protections against illegal content for all 
users. The government will continue to keep online safety policy under review and identify areas where 
we can build on the Act, so it is important for me to be made aware of online safety related Reports to 
Prevent Future Deaths.   

Yours sincerely, 

Secretary of State for Science, Innovation and Technology
Response from National Crime Agency (PDF)
OFFICIAL 

National Crime Agency 
PO Box 8000 
London 
SE11 5EN 

 238 2357  
charles.yates@nca.gov.uk 

Emma Hilson 
HM Area Coroner, Cornwall 
and the Isles of Scilly 
By e-mail only 

25 March 2024 

Dear Ms Hilson, 

Thank  you  for  your  letter  of  1  February  2024  in  relation  to  the  death  of  Guy 
Douglas Scotchford. 

I would like to say how deeply saddened I was to read about the circumstances 
of Mr Scotchford’s death. I would like to offer my condolences to his family and 
loved ones. 

Thank you for bringing to my attention your concerns regarding the availability 
of inert gasses and information regarding suicide methods online. 

The  NCA  recognises  that  the  sale  of  nitrogen  and  other  inert  gasses  is  not  in 
itself  prohibited  due  to  their  many  uses,  primarily  in  industry,  which  include 
within  hydraulic  systems,  cooling  applications,  creation  of  various  beverages, 
and  food  packaging.  The  Health  and  Safety  Executive  sets  out  and  enforces 
regulations in respect of the safety standards of gas canisters but this does not 
extend to who can purchase the canisters. 

As a result of your letter we have been engaging with Ofcom, the online safety 
regulator  under  the  Online  Safety  Act  2023,  to  scope  out  how  we  can  work 
effectively  together,  within  our  respective  roles,  to  combat  suicide  content 
online. The NCA understands that Ofcom is in the process of consulting on its 
draft codes of practice and guidance that will explain the steps  that regulated 
online  services  will  need  to  take  to  meet  their  legal  duties  under  the  Act  to 
protect their users in the UK from this sort of content. 

The  NCA  also  welcomes  the  government’s  commitment  to  reducing  the  lives 
lost  to  suicide  set  out  in  the  Suicide  Prevention  strategy,  published  on  11 

Leading the UK's fight to cut serious and organised crime 
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September  2023  by  the  Department  of  Health  and  Social  Care,  The  strategy 
sets  out  national  ambitions  for  suicide  prevention  over  the  next  5  years,  and 
includes a wide range of individuals and organisations having a role to play in 
suicide prevention.  As a consequence of the strategy, all areas of the country 
now  have  local  suicide  prevention  plans,  including  guidance  on  providing 
bespoke  support  to  specific  groups  and  communities  of  concern,  including 
those who have been in contact with mental health services. I understand this 
is supported by a £57 million investment through the NHS Long Term Plan. 

Within  the  strategy,  the  NCA  particularly  welcomes  the  references  to 
continuing  to  support  search  engine  and  social  media  platforms  to  remove 
content that encourages suicide and provide ready access to suicide prevention 
services, and the read across to the Online Safety Act 2023. The strategy also 
aims  to  clearly  define  who  is  responsible  and  accountable  for  keeping  the 
public safe from this content. Work so far has involved high quality signposting 
and  support  being  prevalent  across  a  wide  range  of  platforms.  A  recent 
example  of  the  latter  is  the  Google  OneBox,  a  pop-up  alert  that  provides 
details  about  how  to  contact  Shout,  a  mental  health  support  service,  or  the 
Samaritans. 

The strategy foreshadows the  recently enacted Online Safety Act 2023, which 
you will no doubt be familiar with. This Act requires all in-scope companies to 
tackle  illegal  content,  such  as  suicide  and  self-harm  content.  Requirements 
have also been made that the largest services will have to offer adults optional 
tools  to  limit  their  exposure  to  legal  content  that  encourages,  promotes  or 
provides instructions for suicide or self-harm. A further extension of this is the 
Criminal  Justice  Bill,  introduced  to  the  House  of  Commons  on  14  November 
2023,  and,  at  the  time  of  writing,  is  in  its  reporting  stage  at  the  House  of 
Commons.  Sections  11  and  12  of  this  bill  look  to  replace  Section  184  of  the 
Online  Safety  Act  2023  with  a  broader  offence  covering  “any  act  capable  of 
encouraging  or  assisting  serious  self-harm  of  another  person”,  with  an 
emphasis on harmful intent. 

The handbook in question also describes a number of drugs that may be used 
for  suicide  purposes  and  which  are  classified  as  Class  A  and  Class  B  under 
schedules  2  and  3  of  the  Misuse  of  Drugs  Act  1971.  These  are  being  tackled 
under the HMG Drugs Strategy, by prioritising breaking drug supply chains and 
limiting the volume of illicit drugs available in the UK. 

I  also  wanted  to  bring  to  your  attention  the  work  that  the  Department  of 
Health and  Social Care are doing with  the Samaritans on the delivery of their 
online  excellence  programme.  This  involves  developing  a  hub  of  excellence  in 
suicide  prevention  and  the  online  environment,  working  in  partnership  with 
Leading the UK's fight to cut serious and organised crime 
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Facebook,  Instagram,  Google,  YouTube,  Twitter  and  Pinterest  and  aims  to 
promote  consistently  high  standards  across  the  sector.  This  will  be  crucial  in 
changing the availability of harmful content online. 

Thank  you  for  bringing  your  concerns  to  our  attention.  I  hope  you  find  this 
summary of the work being done across the government and the NCA, helpful.  

If I can be of any further assistance please do not hesitate to contact me. 

T/Deputy Director 
Borders & Commodities 
National Crime Agency 

Leading the UK's fight to cut serious and organised crime 
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OFFICIAL

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