Daniel Tucker

From Maria Caulfield   
Parliamentary Under Secretary of State   
Department of Health & Social Care   

39 Victoria Street   
London   
SW1H 0EU   

Michael Wall    
Assistant Coroner    
Area of Nottingham City and Nottinghamshire   

7 June 2024   

Dear Mr Wall,     

Thank you for the Regulation 28 report to prevent future deaths dated 29 February 2024 
about the death of Daniel Mark Edward Tucker. I am replying as Minister with responsibility 
for Mental Health and Women’s Health Strategy.        

Firstly, I would like to say how deeply saddened I was to read of the circumstances of  
Daniel Tucker’s death, and I offer my sincere condolences to their family and loved ones. I 
can only begin to imagine the effect that this will have had on his loved ones and, whilst I 
know that it will come as little comfort to them, I nevertheless hope they will accept my 
heartfelt condolences.     

In preparing this response, Departmental officials have made enquiries with NHS England.    

, Ambulance Emergency 

On your concern regarding ingestion of 
Operation Centres (EOCs) use one of two approved triage tools to take 999 emergency 
calls – Medical Priority Dispatch System (MPDS) or NHS Pathways. At the time of the calls 
being made to East Midlands Ambulance Service NHS Trust (EMAS) in Mr Tucker’s case, 
EMAS were users of the protocols within the MPDS. This protocol generates a specific 
‘Determinant Code’ for overdose, following the initial assessment of the patient. This then 
allows the relevant Ambulance Emergency Operation Centre (EOC), in this case that of 
EMAS, to locally determine and apply a local response mode or ‘Category’. The response 
modes are underwritten by the NHS England Emergency Call Prioritisation Advisory Group 
(ECPAG) and sent to NHS Ambulance Service Trusts in England for implementation.    

The MPDS does specifically code some common overdose/poisoning agents, but this is for 
the provision of specific therapies and information for responders rather than for specific 

   
   
   
   
   
 
 
 
  
   
   
   
   
   
 response assignment. The listing of all possible fatal agents would likely lead to significant 
over-triage and delay as many of these patients are asymptomatic and do not represent 
pre-arrival emergencies.    

The code assigned to intentional overdose (intent to harm self) cases, specifically patients 
without priority symptoms, is intentionally isolated so that agencies can prioritise intentional 
acts and respond appropriately, regardless of the substance information offered by the 
caller. Due to the broad spectrum of potentially dangerous substances that can be 
ingested by members of the public, either intentionally or accidentally, coupled with the 
urgent and emergency care (UEC) challenges and delayed response times currently faced 
by the NHS, it is recommended by the MPDS (and NHS England) that ambulance trusts 
utilise trained clinicians in the control centre to advise further on the potential effect of 
ingestions and upgrade responses if deemed necessary. The MPDS also has protocols for 
overdose patients as well as those patients with mental health conditions that are suffering 
any self-harm or suicidal thoughts. Since the time of this call, specific training and a new 
protocol have been developed specifically for first party callers in crisis.   

EOCs follow specific principles to ensure clinical oversight for patients calling and 
presenting with overdose and suicidal ideations. These principles have been reviewed and 
strengthened through several national recommendations since 2019.    

NHS England issued guidance for Ambulance Services relating to overdoses and suicidal 
intent in April 2021. The guidance highlights the critical importance of clinical oversight and 
review and sets out that where an overdose is declared, further clinical intervention should 
take place, or the case should be automatically upgraded if this does not occur within a 
specified time (30 minutes). This is for use by experienced clinicians and lends itself more 
to a consultation-led assessment rather than triage. Most recently, the overdose guidance 
was updated in November 2023 to include callers who reach a Category 5 disposition  
(hear and treat). This followed a review by the Emergency Call Prioritisation Advisory   
Group (ECPAG, NHS England) and the National Ambulance Service Medical Director’s 
Group (NASMeD, Association of Ambulance Chief Executives) to ensure it remained 
clinically fit for purpose.   

I also understand that Joint Royal Colleges Ambulance Liaison Committee (JRCALC) who 
produce clinical guidelines for UK paramedics is currently working with the National 
Poisons Information Service (NPIS) colleagues/experts to update the JRCALC overdose 
and poisoning guidance.   

The Government has taken steps to reduce access to and awareness of this substance. 
DHSC has led an emerging methods working group to prevent awareness and access to 
substances such as this one. This involves close working across government and with 
others to ensure rapid, targeted action has been taken to prioritise tackling the substance 
in question. The working group involves representatives from the voluntary, community and 
social enterprises sector, police as well as government departments including the Home 
Office and The Department for Science, Innovation and Technology as well as academics 
and the NHS.  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 as well as reducing references to, and limiting awareness of, 
emerging methods.    

The group has worked with business, including online suppliers and manufacturers of the 
substance, to significantly reduce access. We have also worked with major online 
suppliers also remove it from sale to individuals in its pure form. We continue to work 
operationally with our broader partners, including Border Force and the police on 
interventions to reduce access to this specific substance for the purpose of suicide. These 
actions are kept under operational review.    

I would also like to assure you that the Government has also taken action to address the 
prevalence of harmful suicide and self-harm content online such as the website you 
highlighted. For example, as you will be aware, the Online Safety Act, when fully in force, 
will require all services in scope to rapidly remove regulated content that meets the 
criminal threshold once they become aware of it, this includes illegal suicide and self-harm 
content. Under the Act, search services also have targeted duties that require them to 
minimise the risk of users encountering illegal search content, such as those found on this 
specific website.  There is also a requirement for search services to take or use, where 
proportionate, 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, as well as signposting users towards sources of support.   

The Act provides Ofcom with a robust suite of enforcement powers, including business 
disruptions measures and significant fines for use in the case of non-compliance. The 
Government has also worked with internet service providers, tech companies and 
social media platforms, as well as expert advisors such as the Samaritans, to tackle 
harmful pro-suicide forums such as this one.   

In addition, in September 2023 the multi-sector and cross-government suicide prevention 
strategy for England was published.  The five-year strategy set out over 130 actions aimed 
at reducing the rates of suicide in England.   

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

Yours sincerely,     

 MARIA CAULFIELD

Michael Wall 
Nottinghamshire & Nottingham  
HM Coroner’s Service 
The Council House 
Old Market Square 
Nottingham  
NG1 2DT  

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

26th April 2024  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Daniel Mark Edward 
Tucker who died on 22 April 2022.   

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  29 
February 2024 concerning the death of Daniel Mark Edward Tucker on 22 April 2022. 
In advance of responding to the specific concerns raised in your Report, I would like 
to express my deep condolences to Dan’s family and loved ones. NHS England are 
keen to assure the family and the coroner that the concerns raised about Dan’s care 
have been listened to and reflected upon.   

In your Report, you addressed a concern to NHS England that confirmed ingestion of 
  during  a  999  call  does  not  trigger  a  Category  1  ambulance 

response.  

Ambulance  Emergency  Operation  Centres  (EOCs)  use  one  of  two  approved  triage 
tools to take 999 emergency calls – Medical Priority Dispatch System (MPDS) or NHS 
Pathways. At the time of the calls being made to East Midlands Ambulance Service 
NHS Trust (EMAS) in Dan’s case, EMAS were users of the protocols within the MPDS, 
for which there is a protocol. This protocol generates a specific ‘Determinant Code’ for 
overdose, following the initial assessment of the patient. This then allows the relevant 
Ambulance  Emergency  Operation  Centre  (EOC),  in  this  case  that  of  EMAS,  to 
consider  the  Determinant  Code  and  locally  determine  and  apply  a  local  response 
mode  or  ‘Category’.  The  response  modes  are  underwritten  by  the  UK  Government 
Emergency  Call  Prioritisation  Ambulance  Group  (ECPAG)  and  sent  to  NHS 
Ambulance Service Trusts in England for implementation.  

While ingestion of 
 can lead to fatality, this can unfortunately be said of 
an  array  of  substances,  ranging  from  prescription  medicines  to  over-the-counter 
household products and other agents available commercially or over the internet. The 
MPDS does specifically code some common overdose/poisoning agents, but this is 
for the provision of specific therapies and information for responders rather than for 
specific response assignment.1 The listing of all possible fatal agents would likely lead 

1 NHS Pathways, the alternative triaging system, also has a disposition code to facilitate improved 
visibility of overdose and suicide attempt cases within the ambulance dispatch code. It also provides a 

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
 
 
 
  
 to significant over-triage and delay as many of these patients are asymptomatic and 
do  not  represent  pre-arrival  emergencies.  Additionally,  the  type  and  amount  of 
substance  taken  is  not  always  reliably  obtained  as  patients  attempting  suicide  can 
mislead  responders.  Therefore,  listing  specific  agents  and  amounts  with  the 
expectation  that  non-clinician  Emergency  Dispatchers  make  response  assignment 
decisions  based  on  what  may  well  be  inaccurate  information  would  likely  result  in 
significant  and  potentially  dangerous  triage  practice.  The  BRAVO-Level  code 
assigned  to  intentional  overdose  (intent  to  harm  self)  cases,  specifically  patients 
without  priority  symptoms,  is  intentionally  isolated  so  that  agencies  can  prioritise 
intentional  acts  and  respond  appropriately,  regardless  of  the  substance  information 
offered by the caller. 

Due to the broad spectrum of potentially dangerous substances that can be ingested 
by members of the public, either intentionally or accidentally, coupled with the urgent 
and emergency care (UEC) challenges and delayed response times currently faced 
by the NHS, it is recommended by the MPDS (and NHS England, please see below) 
that ambulance trusts utilise trained clinicians in the control center to advise further on 
the potential effect of ingestions and upgrade responses if deemed necessary. The 
MPDS also has protocols for overdose patients as well as those patients with mental 
health conditions that are suffering any self-harm or suicidal thoughts.  Since the time 
of this call, specific training and a new protocol have been developed specifically for 
first party callers in crisis.  

EOCs  follow  specific  principles  to  ensure  clinical  oversight  for  patients  calling  and 
presenting with overdose and suicidal ideations. These principles have been reviewed 
and strengthened through several national recommendations since 2019, see below. 

Firstly, on 2 April 2019, 
 – then National Clinical Director 
for  Urgent  and  Emergency  Care  at  NHS  England  –  wrote  to  ambulance  trusts  and 
NHS 111 providers to mandate that robust clinical oversight was in place in control 
rooms and call centres to monitor self-harm and suicidal patients safely and effectively. 

Secondly,  in  2020,  the  Healthcare  Safety  Investigation  Branch  (HSIB),  investigated 
the potentially under-recognised risk of harm from the use of propranolol. They made 
a safety recommendation for NHS England to evaluate current approaches to clinical 
oversight of overdose calls within ambulance control rooms, and to develop a national 
framework  to  describe  requirements  for  appropriate  clinical  oversight  of  overdose 
calls.  

NHS  England  issued  guidance  for  Ambulance  Services  relating  to  overdoses  and 
suicidal intent in April 2021. The guidance highlights the critical importance of clinical 
oversight and review and sets out that:  

•  where an overdose is declared, further clinical intervention should take place, 
or  the  case  should  be  automatically  upgraded  if  this  does  not  occur  within  a 
specified time (30 minutes).  

telephone consultation tool called Pathways Clinical Consultation Support System (PaCCS). This is 
for use by experienced clinicians and lends itself more to a consultation-led assessment rather than 
triage 

 
 
 
 
 • 

• 

it is good practice for TOXBASE® (clinical toxicology database) to be viewed 
for each overdose / accidental ingestion incident, despite the familiarity of the 
reviewing  clinician  with  that  particular  toxicity  profile,  which  includes 

. It  is  noted  that  management  practices  often  change  in  relation  to 
specific toxins, therefore guidance around the use of TOXBASE ® was issued 
instead. 

the initial clinical review should also consider any ongoing suicidal ideation with 
a specific plan / means.   

Most  recently,  the  overdose  guidance  was  updated  in  November  2023  to  include 
callers who reach a Category 5 disposition (hear and treat). This followed a review by 
the  Emergency  Call  Prioritisation  Advisory  Group  (ECPAG,  NHS  England)  and  the 
National  Ambulance  Service  Medical  Director’s  Group  (NASMeD,  Association  of 
Ambulance Chief Executives) to ensure it remained clinically fit for purpose.  

I would also like to provide further assurances on national NHS England work taking 
place around the Reports to Prevent Future Deaths. All reports received are discussed 
by  the  Regulation  28  Working  Group,  comprising  Regional  Medical  Directors,  and 
other clinical and quality colleagues from across the regions. This ensures that key 
learnings and insights around preventable deaths are shared across the NHS at both 
a national and regional level and helps us pay close attention to any emerging trends 
that may require further review and action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,   

National Medical Director

Nottinghamshire Healthcare NHS Foundation Trust 
Duncan Macmillan House 
The Resource 
Porchester Road 
Mapperley 
NG3 6AA 

26 April 2024 

Private and Confidential 

Dear Mr. Wall 

Regulation 28 Response – Mr. Daniel Tucker – April 2022 

Please  find  below  the  Organisational  response  to  the  received  Regulation  28  Report  to 
Prevent Deaths following the death of Mr. Daniel Tucker, the inquest of which was concluded 
on the 6 February 2024. We offer our continued sincere condolences to Mr. Tucker’s family. 

1. A continuing practice/culture of minimising the importance of a ward specific risk 
assessment and care plan.  
I  am  concerned  that,  notwithstanding  the  existence  of  a  clear,  appropriate  policy  and 
significant commendable actions by the Trust since Daniel’s death to address this issue, 
there remain clinical and nursing staff who do not fully recognise or accept the importance 
of completing and utilising the required risk assessment and care plan. This suggests there 
may be a persisting training or cultural issue. 

Response:  

The Trust expectation remains that care plans and risk assessments are individualised and 
fully updated following the 72-hour assessment period. Throughout a  person’s admission 
care plans and risk assessments are expected to be kept contemporaneous and accessible 
to all staff to support a patients care.  At the inquest evidence was provided about how an 
improvement in care planning had been demonstrated and the oversight of this is a continual 
process to ensure this is maintained. A monthly audit is completed which is shared within 

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 the clinical team to ensure any discrepancy for expectations is addressed and updated. The 
latest figure for this from March 2024 was 81% compliance with care planning expectations. 

The oversight of care planning is a feature of the Trust rapid improvement programme.  This 
is a Trust board supported priority focus to improve the quality within adult mental health 
(AMH) service inpatients wards. With regards care planning the emphasis of this work has 
been the engagement of our patients regarding their experience of care planning. Secondly 
the Trust is looking to move to an alternative care planning tool through the Dialog+ model.  
This is an evidence-based tool which has received positive feedback in their evaluations. 
AMH’s  Head  of  Nursing  colleagues  are  involved  in  supporting  the  implementation  plans.  
Additionally,  an  allocated  worker  model  is  in  the  implementation  phased  at  Highbury 
Hospital.    This  sets  a  key  expectation  of  allocated  staff  members  to  have  a  deep 
understanding  of  individual  care  plans  on  each  clinical  shift  to  ensure  effective  and 
meaningful care is offered in line with said care plan. This will be in addition to a named 
nursing team. 

Regarding risk assessments this is also a feature of the rapid improvement work with clear 
emphasis in the understanding of risk within the clinical areas. A key element of this is the 
introduction of safety huddles which is within the pilot stage within AMH before role out to 
all wards. These safety huddles support the team to reflect on the dynamic risks within the 
ward  ensuring  risk  is  well  understood  and  shared  amongst  the  team  to  ensure  effective 
robust plans are in place. 

Trust  guidance  relating  to  risk  assessment,  formulation  and  safety  planning  has  been 
reviewed  in  line  with  NICE  guidelines  and  the  latest  updates  from  NHSE  and  suicide 
prevention evidence and literature. Nottinghamshire Healthcare’s Trust Lead for Self-harm 
and Suicide Prevention is leading this work and has met with NHSE and other leaders in 
suicide prevention to scope good practice and share learning. Updated guidance is reflected 
in the Trust’s new Clinical Risk and Safety Policy (due to be ratified early May 2024) and 
guidance documents relating to psychosocial assessment, formulation, and safety planning 
in  relation  to  suicidality,  including  self-harm  have  been  developed.  Audits,  and  risk  and 
safety forms within healthcare records (including risk and safety assessments, formulation 
and care and safety planning forms) are being reviewed and updated to reflect the latest 
guidance, and support improvement and safety. In April 2024, the Trust also commenced 
development of a Trust Clinical Risk and Safety Panel, to provide governance and guidance 
relating to clinical risk and safety, including policy, training, and support for complex cases. 

Suicide  prevention  and  self-harm  training  was  reviewed  and  enhanced  in  early  2024,  to 
provide assurance re quality and oversight, and include updated self-harm awareness and 
response  training  in  addition  to  suicide  prevention  awareness  and  response  training  for 
compliance  with  NICE  guidelines  and  to  support  consistent  language,  content,  and 
approach.  This  training  continues  to  be  supported  by  Learning  and  Organisational 

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA 

 
 
 
 
 
 
 
 
 
 Development but is now coordinated and assurance provided  by the Trust Lead for Self-
harm and Suicide Prevention and the suicide prevention training team regarding quality and 
consistency of training. The Suicide Prevention team also work with clinical teams to support 
implementation of good practice and guidance in relation to self-harm and suicide prevention 
with  a  further  8  colleagues  from  within  the  Care  Groups  becoming  licenced  Train  the 
Trainers in March 2024 with supervision and support (including co-delivery) from the training 
team to support further implementation. 

Mandatory training for risk is at 85% for Redwood 1 at Highbury Hospital.  This is monitored 
by  senior  leads  to  support  staff  to  attended  to  this  training.    Additional  training  that  may 
support  staff’s  confidence  with  regards  risk  is  being  considered  to  augment  existing  risk 
assessment training. 

The need for clear risk assessment and care planning lead to the review of MDT records 
and an improved template to capture discussions and plans in a more meaningful manner 
has been completed by AMH Clinical Directors.  This has been launched and is due for full 
evaluation in July 2024. 

2. Inadequate system of allocating a named nurse to patients and recording the same 
I am concerned that, notwithstanding the existence of a clear, appropriate policy requiring 
the  same,  the  current  system  of  allocating  a  named  nurse  and ensuring  patients  receive 
regular and effective 1:1 sessions with them are inadequate. I am also concerned that no 
record is kept of the named nurse appointed to each patient, thus (as in this case) 
hindering any investigation where issue around the role and actions of that person arises. 

Response: 

It was recognised within the inquest that an urgent review was needed for the system of 
named nursing  within AMH inpatient  acute wards.  This work is being  led  by  the  Head of 
Nursing at Highbury Hospital. The expectation would be for named nurses to be allocated 
on admission and wherever possible this should be the admitting nurse due to continuity of 
care.    Where  this  is  not  possible  for  example  where  a  staff  member  will  be  taking  some 
annual  leave,  an  alternative  nurse  anticipated  to  be  working  within  the  72  hours  will  be 
allocated.    This  is  current  work  in  progress  and  in  the  engagement  phase  with  the  ward 
teams. 

To ensure that all patients know of their named nurses and that there is a clear record of 
this an interim measure has been agreed for the named nurse to be cleared detailed within 
the care plan.  For the patients experience this will mean that upon receipt of their care plan 
they will have this detail to hand and will be confident of who their named nurse is.  This will 
also  provide  a  record  should  the  identification  of  the  named  nurse  be  required  for 

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA 

 
 
 
 
 
 
 
 
 
 
 
 
 governance  processes  such  as  an  investigation.  Audits  will  now  be  ongoing  to  support 
oversight and compliance.   

Longer  term  the  allocated  worker,  as  detailed  in  point  1,  and  the  named  nurse  work  will 
feature as part of the nurse’s development through training, coaching and support to fully 
understand the roles and the importance this has for high quality and safe patient care. 

3. Inadequate skills/knowledge/training on how to encourage patients to engage 
I am concerned that clinical, nursing and/or support staff may not currently have sufficient 
skills or knowledge in dealing with patients who appear unable or unwilling to engage with 
staff and/or treatment. 

Response:  

Mr. Tucker had very clear reasons for seeking an alternative bed which may have supported 
his engagement with the team. Whilst Mr. Tucker was recorded on a transfer list seeking an 
alternative bed this process was no robust enough. The process has since been reviewed 
which saw the transfer procedure reviewed to ensure the full MDT was explicitly clear of the 
need for transfer and rationale for this.  In addition, our bed management recording has been 
amended to hold a single bed list to include all admissions and transfers. This now offers a 
clear oversight and allows for prioritisation based on all known factors. 

To further support clinical training oversight, the Trust has a newly formed Clinical 
education steering group which is a strategically led group with representation from senior 
staff within learning and development and clinical practice. The remit for this group is to 
carry out a comprehensive review of all training, both mandatory, essential and desirable, 
across the whole of the trust to align with the needs of each care group. The group will 
carry our mapping exercises on current provision and sign off new training to ensure it 
meets the quality and safety requirements for the staff attending. The review will align with 
the NHSE optimize, rationalize and reform plan. The group has clear governance 
procedures which will guide the review and implementation. It will allow clear data to be 
produced so that the care group needs can be met in a timely manner, by adapting the 
training delivered according to the needs of the service. 

More  specifically,  additional training  has  commenced  to  support staff  which  has  included 
additional suicide awareness through formal training over January 2024 – 78% of Redwood 
1 staff attended during this month, additional training is being arranged for those unable to 
attend in January and new starters that have joined the team since. Alongside this bitesize 
training  sessions  were  made  available,  and  training  is  in  development  regarding  positive 
behavioural support.  The Trust have invested in additional self-harm and suicide prevention 
training – Storm which is due to start to roll out in June 2024.  

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA 

 
 
 
 
 
 
 
 
 
 
 
 
 
 I would once again express our deepest condolences to Mr. Tucker’s family.  

Yours sincerely  

Executive Director of Nursing AHPs and Quality 

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA

Classification: HIGHLY SENSITIVE

CONFIDENTIAL

Michael Wall 
His Majesty’s Assistant Coroner, Nottingham 
City and Nottinghamshire   

26 April 2024 

Dear Mr Wall, 

We write in response to the Regulation 28 report to Prevent Future Deaths, received 1st March 2024, 
which was issued to Ofcom following the death of Daniel Tucker (‘the Report’).  

Firstly, I would like to offer my deepest condolences to Mr Tucker’s family and loved ones on behalf 
of Ofcom. I understand that a loss in such troubling circumstances must be incredibly difficult.  

Our response will necessarily focus only on the issues raised in the report which are within Ofcom’s 
remit, namely, the ‘continuing accessibility of the pro suicide web-forum, 
with 
reference to new legal requirements under the Online Safety Act 2023 (‘the Act’).  

We thank the coroner’s office for bringing our attention to the role of online services in the tragic 
circumstances of Mr Tucker’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.  

I wish to assure you and the family of the deceased that Ofcom is committed to taking action to 
ensure that all online services in scope of the Act fulfil their duties in regard to harmful suicide 
content, as we press forward in our implementation of the Act’s provisions.  

i. 

Response to Regulation 28 report following inquest into the 
death of Daniel Tucker 

In the response below, 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 Act and 
relate to Ofcom’s plans for implementation of the Act as the UK’s regulator for online safety. 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, following the Act coming into force on 26 October 2023. Until the relevant procedural steps 
outlined below are completed, the duties on regulated services are not yet fully in force. As Ofcom’s 
enforcement powers are tied to non-compliance with these duties, we will only be able to pursue 
enforcement action against online services once our Codes of Practice are finalised in 2025. Once 

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

the duties are in force, we won’t hesitate to exercise our enforcement powers where appropriate 
and effective to protect Internet users.  

Following reports1 of alleged illegal and harmful suicide content on 
contacted the service on 7 November 2023, which subsequently announced via its website that UK 
users would be blocked. On January 8 2024, we contacted the service again to note we were aware 
that the restrictions appeared to no longer be in place. At the time of writing, we are aware that the 
site is accessible by UK users. This is a situation which we will continue to monitor, but as noted 
above, Ofcom does not have powers to enforce these duties until the relevant guidance and Codes 
have been finalised and come into force. 

, Ofcom 

As a provider of a service that allows user-to-user sharing of content and that is accessible in the UK, 

 is likely to be in scope and subject, in particular, to the illegal content duties 

found in sections 9 and 10 of the Act, which we outline in further detail below. This means that if the 
site is still accessible to UK users in its current form when these duties take effect, we would then be 
able to carry out an initial assessment to explore whether the available evidence merits opening an 
investigation, whether the issue can be resolved through other means, and whether it should be 
prioritised. Our published enforcement guidance sets out the framework within which we will make 
these decisions.  

If, following a formal investigation, we are satisfied that the company concerned has contravened 
one or more of its obligations under the Act, Ofcom may issue a notice of contravention, impose a 
financial penalty and/or require steps to be taken to remedy the harm or come into compliance. 
Should the service fail to comply with these remedial steps (or pay the financial penalty), we can 
apply to the court for business disruption measures, which include service restriction orders or 
access restriction orders. 

In exceptional circumstances, we may consider it appropriate to apply for a business disruption 
measure before taking formal enforcement action. 

Below we set out in more detail the steps and approach we are taking to implement the Act, 
estimated timelines, and in-scope services’ legal duties to comply with the Act.  

 The Online Safety Act 2023 

The Online Safety Act 2023 (‘the Act’) 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.  

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 

Page 2 of 8 

 
 
 Classification: HIGHLY SENSITIVE 

Provisions of the Act: legal duties on services 

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. These include: 

o  duties on user-to-user services to swiftly take down illegal content (including illegal 
suicide and illegal self-harm content) when it is identified, and to prevent children 
from encountering content that is harmful to them (including content which 
encourages, promotes or provides instructions for suicide or self-injury); 

o  duties on search services to minimise the risk of individuals encountering illegal 
content (including illegal suicide and self-harm content) and children from 
encountering content that is harmful to them (including content that encourages, 
promotes or provides instruction for suicide or deliberate self-harm) in search 
results; and 

o  additional duties for the largest and highest-risk services allowing their users to 

increase control over the content they encounter on those services.  

•  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. These include Codes of Practice 
setting our recommended measures services can take to mitigate risks of harm in 
compliance with their duties, and resources to help companies assess, understand and 
manage risk.  

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

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’3). 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 

3 ‘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. See our advice on 
categorisation: Categorisation Research and advice (ofcom.org.uk) 

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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. 

Timeline for duties under the Act coming into force 

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: the 
completion of public consultations (the first, on illegal harms, closed on 23rd February 2024); services 
completing Risk Assessments designed to help them understand 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 three key phases of work over the next 
three years. 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. 

  Figure 1: Ofcom’s timeline for Online Safety implementation

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 

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our internal expertise in relation to this complex and important harms area, including by 
commissioning research.4 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: Illegal Harms 

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

We have also consulted 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 Risks.  

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.5 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.6 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;  

4 See, for example, our recent research on suicide content and search services: ‘One Click Away: a study on the prevalence 
of non-suicidal self injury, suicide, and eating disorder content accessible by search engines’. See also our research into 
children’s experience of suicide, self-harm and eating disorders content: ‘Experiences of children encountering online 
content relating to eating disorders, self-harm and suicide’ 
5 Section 41 of the Act 
6 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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•  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 
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.7 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.  

 The Illegal Harms consolation closed on 23rd February 2024. We are now reviewing responses to our 
consultation and working towards our Illegal Harms Statement, in which we will outline our final 
policy decisions. 

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 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 

7 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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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: Child Safety 

As stated above, services that are likely to be accessed by children are required to protect children 
from legal content which may harm them. As part of Phase Two, we will publish a consultation on 
protecting children, to be published in May 2024, which 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.  

After publication of our final guidance on Children’s Risk Assessments (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: transparency, user empowerment, and other duties on categorised 
services 

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

The user empowerment duties will contain 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 issued a Call for Evidence regarding our approach to phase 
three on 25 March 2024.  

iii.  Conclusion 

We thank the Coroner again for bringing to our attention the role that access to online services had 
in Mr Tucker’s death. His story highlights the pressing importance of tackling the harm from services 
which provide ready access to suicide content. 

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.  

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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 and 
vulnerable users.  

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. And where we identify non-compliance, we will not hesitate to take appropriate 
enforcement action to protect users from harm.  

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, 

Chief Executive 

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