Source · Prevention of Future Deaths

Bronwen Morgan

Ref: 2023-0409 Date: 25 Oct 2023 Coroner: Graeme Hughes Area: South Wales Central Responses identified: 0 / 4 View PDF

Vulnerable individuals are able to access websites that facilitate and promote self-harm and suicide methods, enabling them to acquire information and means to cause their own death.

Date 25 Oct 2023

56-day deadline 20 Dec 2023

Responses identified 0 of 4

Suicide (from 2015) Wales prevention of future deaths reports (2019 onwards)

Coroner's concerns

AI summary

Vulnerable individuals are able to access websites that facilitate and promote self-harm and suicide methods, enabling them to acquire information and means to cause their own death.

View full coroner's concerns

The evidence revealed that as from at least February 2020, BM had registered with, & was engaging in discussion forums This website was mentioned in an earlier PFD Report dated 3.12.19 (copy annexed). The engagement that BM had with the website encompassed her discussing & seeking advice from fellow users in respect of, methods of self-harm/suicide including the purchasing & use of the substance . This was the substance used by BM which led to her death. The concern here is that this site & potentially similar self-harm & suicide “facilitating, or promoting” sites are accessible/available to those, such as BM who are vulnerable, due to their diagnosed, or otherwise mental illness & provided with an outlet/forum to source & acquire information that potentially equips them with the knowledge & means to either complete suicide, or place them in grave/greater danger of doing so. I believe that consideration ought to be given to the impact such access/availability has upon those vulnerable individuals researching/contemplating acts of self-harm & whether, & what action(s) may be taken to remove/limit/mitigate/educate such access/availability.

Report sections

Investigation and inquest

On 10 September 2020 I commenced an investigation into the death of Bronwen Grace MORGAN (BM) . The investigation concluded at the end of the inquest 20/10/2023. The conclusion of the inquest was Suicide. 1a Toxicity 1b 1c II

Circumstances of the death

Bronwen Morgan had a diagnosis of Emotionally Unstable Personality Disorder. This manifested itself in fluctuating symptoms including acute periods of distress and anxiety leading to acts of deliberate self-harm. She was under the care and treatment of local mental health services. She was engaging in dialectical behaviour therapy the indicated treatment for Emotionally Unstable Personality Disorder. On 27.8.20 she has travelled to a hotel possessing a toxic substance that she had purchased .

She was located in the hotel by the emergency services and conveyed to the University Hospital of Wales, Heath. Despite resuscitation attempts she did not regain consciousness and died from the toxic consequences of the substance. Material located on her mobile phone and at the scene demonstrated that she likely intended the consequences of her deliberate actions to be her own death.

Action should be taken

7 YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by 20th December 2023, or if I, the Coroner, extends 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.

Copies sent to

Health Board and Public Health Wales

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2023-0409
Date of report: 25 October 2023
Coroner: Graeme Hughes
Coroner area: South Wales Central

Responses identified

Responses identified 0 of 4

4 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 20 Dec 2023.

Sent to

Department for Digital, Culture, Media and Sport

Ofcom

Welsh Health Minister

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.