Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0199, written 26 Feb 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Feb 2024 |
|---|---|
| Reference | 2024-0199 |
| Deceased | Deborah Cooper |
| Coroner | David Ridley |
| Coroner area | Wiltshire and Swindon |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
HM Senior Coroner
for Wiltshire and Swindon
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
The Head of Amazon Legal Department The Rt Hon Kemi Badenoch MP
Amazon UK The Secretary of State for Business and Trade
1 Principal Place Department of Business and Trade
Worship Street Old Admiralty Building
London Admiralty Place
EC2A 2FA London
SW1A 2DY
The Rt Hon Lucy Frazer KC MP
The Secretary of State for Culture, Media and Sport
Department for Culture, Media and Sport
100 Parliament Street
London
SW1A 2BQ
1
CORONER
I am David Ridley, Senior Coroner for Wiltshire and Swindon
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
Today (22nd February 2024), I received notification from Wiltshire Police as regards the sudden
death of Deborah Jane Cooper whose body was found at her home in Melksham yesterday on
the 21st February 2024. Deborah was aged 61 at the time of her death. I have commenced as
of today’s date a Coronial Investigation into Deborah’s death and will shortly be opening an
Inquest into her death once the postmortem examination has taken place, and I am in a position
to release her body back to the family.
4
CIRCUMSTANCES OF THE DEATH
From information provided by the police I have reason to suspect that her death is unnatural and
given the cherry red complexion noted in relation to photographs that I have seen of Deborah’s
body and the presence of apparatus, some of which was purchased on line from Amazon, it
appears that she has put together an apparatus t
died from carbon monoxide
poisoning. Notes were left at the scene as regards her intention to end her life.
As part of the police report I received photographs taken from her computer of a publication
. My
investigation will establish how she acquired that digital copy. The book essentially contains
instructions on how to make a piece of apparatus
Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
individual’s life.
The book also covers other methods again with the aim of end an
I then Googled the said publication in order to see if the publication could be purchased here in
the UK, which then led me to the Amazon UK site where I found that copies of this publication
were freely available and supplied direct by Amazon UK. N
there was also a similar publication
“was also
marketed in both electronic and paperback formats. This second publication seems to also
suggest that it may contain instructions as to how one goes about ending one’s life.
5
CORONER’S CONCERNS
The law states that a Coroner has a duty to make a Report, such as this report, with a view to
the prevention of future deaths whereas part of an investigation evidence raises such a concern.
That duty in my view has arisen in this case when I discovered that books giving clear
instructions as to how an individual might want to end his or her life was freely available on the
open market on the Amazon.co.uk website. I am concerned that the marketing and supply of
such a book giving such clear instructions and advice as regards different methods for an
individual to end his or her life at their own hands is of the utmost concern as is the regulation as
regards the supply of such publications whose sole purpose is to provide information to those
contemplating on ending their lives.
I have identified 2 publication that give such advice and there may be more currently being
marketed on the Amazon.co.uk website.
I have raised the concern and ask that both Amazon.co.uk and His Majesty’s Government
consider how best to address the concern raised in this letter. It is not for a Coroner to make
recommendations and the limit of my coronial power is limited to airing the concern in the first
place.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you 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
24th April 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 Person,
Family of Mrs Cooper
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 26th February 2024
Amendment Date 24th April 2024
Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Signature_____________ David Ridley, Senior Coroner for Wiltshire & Swindon
Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
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.
15 April 2024 Wiltshire & Swindon Coroner’s Court 26 Endless Street Salisbury, Wiltshire SP1 1DP Attention: David Ridley – HM Senior Coroner for Wiltshire & Swindon Private and Confidential RE: Regulation 28 Report to Prevent Future Deaths (Reference: DR.DT.19656316) Dear Sir/Madam We refer to the Regulation 28 Report to Prevent Future Deaths (“Report”) dated 26 February 2024 (received 28 February 2024). The Report references two books available on Amazon.co.uk: (together, the “Books” and each a “Book”). We offer our deepest sympathies to the family and friends of Mrs Cooper. 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 each Book against our content guidelines, taking account of your comments, and have decided not to remove either of them 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 those 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 referenced in the Report, which presents customers with information on how to access free and confidential advice from the Samaritans. Yours faithfully For and on behalf of Amazon UK Services Limited Legal Department
Kevin Hollinrake
Minister of State
Department for Business and Trade
Old Admiralty Building
Admiralty Place
Whitehall
London
SW1A 2DY
Mr David Ridley
Wiltshire & Swindon Coroner’s Court
26 Endless Street
Salisbury
Wiltshire
SP1 1DP
28 June 2024
Re: Regulation 28 Report to Prevent Future Deaths sent to the Rt Hon Kemi Badenoch
MP, the Secretary of State for Business
Dear Mr Ridley,
I would like to begin by expressing my deepest condolences to the family and friends of
Deborah Jane Cooper following her death and the circumstances that surrounded it. I
recognise the gravity of the concerns raised in your Report and I am grateful for the
opportunity to respond to this Report to Prevent Future Deaths. As we are in a pre-election
period, I apologise that I cannot comment on or commit to further actions to prevent future
deaths as these will be for the new Government.
The Department for Business and Trade is, inter alia, responsible for consumer protection
law, including the Consumer Protection from Unfair Trading Regulations 2008 (“CPRs”),
which is shortly to be updated by Part 4, Chapter 1 of the Digital Markets, Competition and
Consumers Act 2024 (DMCC Act). The DMCC Act received Royal Assent in May 2024.
There is limited scope to address the issues raised in your Report through existing consumer
protection legislation. For example, while the scope of the protection offered to consumers
by the unfair trading legislation (referred to above) is broad, its focus is primarily to protect
consumer’s economic interests. This legislation does not impose a blanket ban on the sale
of the particular products in issue.
However, there is legislation, which falls outside of the scope of my Department’s
responsibilities, which is more directly relevant including section 2(1) of the Suicide Act 1961
(as amended), which makes it an offence for a person to commit 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. It is a matter
for the Police and Crown Prosecution Service to consider and, where appropriate, pursue
prosecutions.
In addition, the new Online Safety Act requires all in-scope services, including in-scope
marketplaces, to rapidly remove regulated content, including suicide content, where they
have reasonable grounds to consider that it crosses the criminal threshold. I understand that
a letter has been issued in response to your Report from the Department for Science,
Innovation and Technology (DSIT) regarding the scope of the Online Safety Act in relation
to these issues. Ofcom is the independent regulator for the Online Safety Act and is working
with the DSIT to implement the Act which received Royal Assent in October.
Yours sincerely,
KEVIN HOLLINRAKE
Minister for Enterprise, Markets and Small Business
Department for Business and Trade
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