Pro-suicide website slammed by coroner in plea to minister to shut it down after tragic death

People still accessing dangerous suicide website a senior coroner has warned

Daniel Tucker died after being discharged from Nottingham Healthcare Foundation Trust (Deborah Tucker)

A coroner has urged ministers to ban a prolific pro-suicide website linked to dozens of deaths in the UK and US, warning further lives could be lost unless it is taken down.

Health secretary Victoria Atkins has been told to shut the forum after a young patient, Daniel Tucker, accessed it while being treated in scandal-hit Highbury Hospital in Nottingham. He was discharged shortly afterwards and took his own life.

Coroner Michael Wall’s warning came as he raised concerns that patients at the mental health hospital - which was responsible for the care of Nottingham killer Valdo Calocane and recently suspended more than 30 staff over misconduct concerns - could be at risk of death or serious harm amid failures by staff to properly use self harm and suicide risk assessments.

He sent a “prevention of future deaths” report to the secretary of state, Ofcom, and NHS England. These reports are from coroners to alert authorities of systemic risks found during inquests which they believe could lead to the deaths of others if they are not addressed.

Mr Wall, who led the inquest into Mr Tucker’s death, said: “Through that forum he was able to engage in discussions with other pro-suicide members and obtain information on the means of taking his own life and on how and where to source those means.”

He told Ms Atkins he recognised that new laws under the Online Safety Act will ban the website and attempts have been made to block it. But he added: “I heard evidence that it remains easily accessible to vulnerable people in the UK. I am concerned that further deaths will occur while this remains the case.”

An inquest heard that Mr Tucker took his own life just hours after being discharged from the hospital, where he accessed the online suicide forum.

The inquest heard he died after ingesting a substance he had learned about on the website. In 2021 the Department for Health and Social Care received five prevention of future deaths reports in the previous three years where patients had ingested the same substance, according to information released following freedom of information requests.

Reports of deaths connected to the substance have also surfaced in both the USA and Canada in recent years.

In the same prevention of future deaths report, the coroner also criticised Nottinghamshire Healthcare Foundation Trust, which runs Highbury Hospital, over patient care concerns.

He said patients are at risk of death in the future due to “persistent training or culture issues”, with staff refusing to perform suicide and self-harm risk assessments.

It comes as the trust faces scrutiny over the suspension of 30 staff members at the same hospital. They face allegations including falsification of medical records, as revealed byThe Independent last month.

Last week, the Care Quality Commission published a report revealing staff at Highbury Hospital were found to have assaulted patients and falsified records. Police are currently investigating the death of one patient in September 2022.

The trust is also the focus of a separate further review by the regulator following the conviction of Valdo Calocane, who killed three people in Nottingham while under the care of Highbury Hospital services.

Valdo Calocane (Nottinghamshire Police/PA)

As a result of the concerns and CQC reports, NHS England has now placed Nottinghamshire Healthcare under its “recovery support” programme, meaning it will be subject to scrutiny by the body for the next year.

Last year parliament passed the Online Safety Bill which will eventually allow regulator Ofcom new powers to act on online harms, including websites which encourage or assist suicide. The law came in following campaigns after the death of 14-year-old Molly Russell in 2017, who took her own life after spending time on sites promoting depression and self-harm.

But the new powers have not yet been implemented. And the site is still accessible, Mr Wall pointed out.

The coroner called for the government and NHS England to upgrade the ambulance category for the substance taken by Mr Tucker as it does not currently come under the most urgent response category.

Daniel Tucker (Deborah)

During a 10-day inquest, it was heard that Mr Tucker had been discharged from the hospital on 22 April, despite having shared suicidal intentions with staff just days before. The jury concluded that failures by staff to ensure an appropriate plan for him contributed to his death.

The coroner added: “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.”

During the inquest, it was also revealed a staff member had doctored the date on discharge paperwork which should have been completed before Mr Tucker’s death.

An Ofcom spokesperson said: “To implement the Online Safety Act, we have to consult on new Codes of Practice and Guidance, which will then be subject to Parliamentary approval. We’re moving at pace through this process and expect to finalise our illegal harms Codes by the end of the year, after which they will become enforceable. And in May, we’ll consult on additional protections for children.”

It added the sites and apps will have to take steps to prevent users coming across illegal material including that which encourages or assists suicide and they will have to act “swiftly” to remove these videos or posts.

Ifti Majid, chief executive of Nottinghamshire Healthcare NHS Foundation Trust said: “On behalf of the Trust, I once again extend our sincere condolences to Dan’s family and friends for their loss. We acknowledge there were aspects of care which were not of the quality they should have been and for we are deeply sorry.”

He said since the time of his death there have been a number of significant change including the introduction of peer support workers and improvements in planning and risk assessments.

A spokesperson for the DHSC said: “Every suicide is a tragedy, and it is already an offence under the Suicide Act 1961 to encourage or assist suicide or an attempted suicide. Our Online Safety Act requires companies to take proactive action to prevent users from encountering illegal content that encourages or assists suicide.”

It said the prioritisation of ambulance incidents is an operational matter for the NHS.

If you are experiencing feelings of distress, or are struggling to cope, you can speak to the Samaritans, in confidence, on 116 123 (UK and ROI), email jo@samaritans.org, or visit the Samaritans website to find details of your nearest branch.

If you are based in the USA, and you or someone you know needs mental health assistance right now, call the National Suicide Prevention Helpline on 1-800-273-TALK (8255). This is a free, confidential crisis hotline that is available to everyone 24 hours a day, seven days a week.

If you are in another country, you can go to www.befrienders.org to find a helpline near you.