- Government departments warned 65 times about pro-suicide forums or substance they promote to end lives but failed to act on warnings
- Multiple missed opportunities to act have exacerbated the risk posed by nihilistic forum and substance, with at least 133 UK lives lost
- Families and survivors write to PM calling for a public inquiry in the face of ongoing and immediate harm
Bereaved families and survivors of a suicide forum have personally called on the Prime Minister to grant a public inquiry into major failures of the State to protect vulnerable young people from the preventable harm caused by the pro-suicide forum that continues to promote, encourage and instruct vulnerable people to take their own lives.
It comes as a new report reveals three Government departments received concerns a combined total of 65 times from coroners about the risks of further deaths from suicide forums and a single substance one promotes, glorifies and instructs for use as a suicide method.
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The substance is believed to have cost at least 133 deaths in the UK, but potentially many more.
Analysis from Molly Rose Foundation and the lived experience group Families and Survivors to Prevent Online Suicide Harms found coroners have raised concerns about either the substance or suicide forums with DSIT/DCMS, the Home Office and Department of Health at least 65 times since 2019.
The report highlights four major areas where governments and public bodies have failed to act quickly or effectively enough in the face of repeated and sustained warnings:
- The Home Office has declined to strengthen regulation of the substance, despite repeated calls. As a result, it remains far too easy for vulnerable people to procure the substance from domestic sellers, while UK Border Force struggles to respond to imports from malign sellers based overseas
- Ofcom is failing to take necessary steps to prevent the ongoing threat posed by the pro-suicide forum to UK users. Last week, the regulator signalled it would choose to rely on voluntary but insufficient measures from the forum’s founders, who seemingly run the site for primarily nihilistic reasons and also run incel forums
- Government departments have played ‘pass the parcel’ rather than take concerted action. Multiple warnings from coroners have been meet with repetitive responses from Government departments, often looking to shift responsibility between each other. There is currently no mechanism to track whether action is taken in response coroners’ concerns
- Operational responses have resulted in missed opportunities: from inconsistent police welfare checks to slow uptake by ambulance services to stock an antidote, multiple opportunities have been missed.
Families have now written to Prime Minister Keir Starmer calling for a public inquiry to identify the scale of harm facilitated by suicide forums; including the impact of countless missed opportunities to prevent the forum from continuing to promote and encourage the use of the substance as a suicide method.
In the letter to the Prime Minister they said: “We write as families whose loved ones were let down by a State that was too slow to respond to the threats, which despite multiple warnings has failed to act to save lives and prevent harm.
“This series of failings requires a statutory response, not just to understand why our loved ones died but also to prevent more lives being lost in a similar way.
“What is important now is not blame but change that will mean more vulnerable young people are not put at risk of entirely preventable harm.”
As well as the families’ letter to the PM a letter has also been sent by law firm Leigh Day on behalf of seven of their clients who have lost loved ones due to the substance and having engaged in the online forum. The legal letter requests that the government exercises its powers under s.1 Inquiries Act 2005 to hold a statutory public inquiry into the large but undetermined number of deaths through ingestion of the substance purchased online.
The letter highlights that the Coronial system cannot consider the adequacy of the regulatory framework, nor make recommendations for meaningful change and therefore a statutory public inquiry is required to address public concern and examine how so many chances were missed to save lives and how the ongoing risk to future lives can be addressed.
Families have warned how loved ones were groomed by users of the forum to end their lives. Victims of both the substance and online forums tended to be in their early 20s, with the youngest known victim of the forum being just 13.
Concerns heightened since the forum first emerged and began to popularise the substance in 2019, but warnings have been ignored with failures to respond to the growing use of the substance as a suicide method and delayed and ineffective action to legally shut down the forum.
Andy Burrows, Chief Executive of Molly Rose Foundation, said: “This report paints clear how repeated failures of the State to protect its vulnerable citizens mean that the nihilistic potential of a suicide forum has cost countless lives.
“It is inexplicable that Ofcom has left the fate of a forum that exists to groom and coerce others to end their lives in its own hands rather than take swift and decisive action to legally shut it down in the UK.
“Nothing less than a public inquiry is now needed to learn the countless lessons and act on them to save lives.”
Munira Wilson MP, Liberal Democrat Education Spokesperson, said: “Today’s report must be a wake-up call to the institutional failures and missed opportunities that have left vulnerable people at risk.
“A statutory public inquiry into the 133 lost lives is an urgent next step and must be conducted swiftly and sensitively to learn lessons and act decisively.
“It is thanks to bereaved families and civil society that this harm has been exposed and now the Government must step up and play its part to save lives.”
Merry Varney, partner at law firm Leigh Day representing seven of the families calling for a public inquiry, said: “The Government is rightly committed to preventing deaths through suicide, yet despite repeated warnings of the risks posed by an easily accessible substance, fatal in small quantities and essentially advertised on online forums, no meaningful steps have been taken. Some coroners have properly investigated these issues and issued reports noting their concerns of the ongoing risks to life. However, other bereaved families have been left to investigate themselves or face a coroner refusing to consider how a deceased acquired the substance and/or the role of online activity including activity on suicide forums, where the deceased may have received assistance or encouragement to end their life.
“With over 100 lives being lost and tens of Prevention of Future Death reports issued, a statutory public inquiry is urgently required to examine how so many opportunities were missed to make effective change. The inquiry should require those responsible to explain why they did not act in the face of such obvious harm. A statutory inquiry will also ensure multi-agency and cross-Department lessons are learned and expose the ineffective regulatory scheme in place after the substance was downgraded in 2015.
“This cannot be achieved through inquests and the coronial process. The families and victims deserve a powerful spotlight being shone on how their loved ones could have been saved and the comfort that could come from knowing that action will be taken to ensure similar dangers are dealt with much more quickly in the future.”
The call for a public inquiry is backed by Molly Rose Foundation, INQUEST, CALM – The Campaign Against Living Miserably, Thomas William Parfett Foundation, The Center for Countering Digital Hate and The Jordan Legacy.
If you’re struggling just text MRF to 85258 so you can speak to a trained volunteer from Shout, the UK’s Crisis Text Line service.
If you’d like to learn more about the lived experience group Families and Survivors to Prevent Online Suicide Harms please contact comms@mollyrosefoundation.org
