Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0159, written 21 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Mar 2024 |
|---|---|
| Reference | 2024-0159 |
| Deceased | Mary Jones |
| Coroner | Elizabeth Wheeler |
| Coroner area | Cheshire |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used before an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 amazon UK 1 CORONER I am Elizabeth WHEELER, Assistant Coroner for the coroner area of Cheshire 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 On 14 November 2023 I commenced an investigation into the death of Mary JONES aged 86. The investigation has not yet concluded and the inquest has not been heard. 4 CIRCUMSTANCES OF THE DEATH Mary Jones was found dead at her home address on 7 November 2023. She had last been spoken to on 6 November. She died as a result of a deliberate overdose of medication, taken with the intent to end her own life. As part of calculating what a fatal dose would be, she consulted a well known book advising on suicide methods. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) The “well known suicide book” I refer to in Box 3 is publication). As part of my investigations, I have received evidence that this book is readily available on Amazon.co.uk following a simple search for the same. Furthermore, it is available on Amazon Prime – so is available for expedited delivery. ” (redact on It is the first item shown when a search is made. Amazon, or the algorithms, are clearly aware of the potential for harm that this book can cause as there is a banner at the top giving contact numbers for the Samaritans. Despite this, the book is still on sale. I am aware that the Area Coroner for Cheshire wrote to Amazon in December 2023 raising this same issue, but has not yet had a response. I am concerned that the ready availability of this book will lead to people being more effective in any attempts to take their own lives. 6 ACTION SHOULD BE TAKEN Regulation 28 – Before Inquest Document Template Updated 30/07/2020 In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 April 26, 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 I have also sent it to who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated: 21/03/2024 Elizabeth WHEELER Assistant Coroner for Cheshire Regulation 28 – Before Inquest Document Template Updated 30/07/2020
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
15 April 2024
Cheshire Coroner’s Court
Museum Street
Warrington
WA1 1JX
Attention: Elizabeth Wheeler – Assistant Coroner for Cheshire
Private and Confidential
RE: Regulation 28 Report to Prevent Future Deaths (Reference: 02481-2023 - Mary JONES)
Dear Sir/Madam
We refer to the Regulation 28 Report to Prevent Future Deaths (“Report”) dated 21 March 2024 (received 22
March 2024). The Report references the following book available on Amazon.co.uk:
We offer our deepest sympathies to the family and friends of Ms Jones.
We have carefully considered the contents of the Report. As a bookseller, we believe that providing access to
written speech and a variety of viewpoints is important, including books that some may find objectionable.
We have content guidelines governing which books can be listed for sale and promptly investigate when a
concern is raised. We have reviewed the Book against our content guidelines, taking account of your
comments, and have decided not to remove it from sale.
We recognise that there are heavily debated titles in our store and different views on where to draw the line
protecting freedom of expression. We carefully consider the types of content we make available and think
broad guidelines to protect freedom of expression, including controversial content, serve readers better than
censorship. We strive to offer a broad selection for customers, even if we don't agree with the message or
sentiment of the book itself.
At the same time, we are committed to taking measures not to surprise customers with potentially
controversial or sensitive content. We display a banner on the product detail page of titles like the Book
referenced in the Report, which presents customers with information on how to access free and confidential
advice from the Samaritans.
AMAZON UK SERVICES LTD.
REGISTERED OFFICE: 1 PRINCIPAL PLACE, WORSHIP STREET, LONDON EC2A 2FA, UNITED KINGDOM
Registered in England and Wales • Company Registration No. 03223028 • VAT No. GB 680 737 022
Yours faithfully
For and on behalf of Amazon UK Services Limited
Legal Department
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