Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Bronwen Morgan · 25 Oct 2023 · Graeme Hughes, South Wales Central
“The concern here is that this site & potentially similar self-harm & suicide”
judiciary.uk/…/bronwen-morgan-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Bronwen Morgan (25 Oct 2023) · stated timescale: none stated
“we are committed to driving industry improvements by engaging with the largest and riskiest services via continuous 'regulatory supervision.'”
Stated action 2 · response to Chloe Macdermott (19 Dec 2023) · stated timescale: none stated
“seeking to tackle at source the suppliers of harmful substances for the purposes of suicide”
Stated action 3 · response to Chloe Macdermott (19 Dec 2023) · stated timescale: once these duties are in force
“The act's illegal safety duties will apply to all in-scope 'user-to-user' services which allow users to post content online, or to interact with each other - including online forums. This means that once these duties are in force, they will be required to have systems and processes in place to proactively prevent users from encountering priority illegal content via their service and to minimise the length of time for which such content is present.”
2 further stated actions are listed on the full chain page.
What recurred
- 19 Dec 2023 · Chloe Macdermott · Paul Rogers
- 12 Mar 2025 · Rhiannon Williams · Kirsten Heaven · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Chloe Macdermott · 19 Dec 2023
“(3) [REDACTED], is a forum that permits material to be exchanged and viewed within its open chatrooms whereby suicide is encouraged, assisted, counselled and procured through the provision and exchange of information and methods.”
Later · Rhiannon Williams · 12 Mar 2025
“[the deceased] accessed an online 'suicide forum' where she was able to access information on how to take her own life”
What happened next
No evidence found either way · stated action 2
“This chapter characterizes the movement of precursor chemicals through domestic supply chains and the potential vulnerabilities inherent in those supply chains, based largely on the presentations provided during the data-gathering meetings.”
Read "Reducing the Threat of Improvised Explosive Device Attacks by Restricting Access to Explosive Precursor Chemicals" at NAP.edu · nationalacademies.org/read/24862/chapter/5
No evidence found does not mean the action did not happen.