Deborah Cooper: Prevention of future deaths report

Suicide (from 2015)

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Date of report: 26/02/2024

Ref: 2024-0199

Deceased name: Deborah Cooper

Coroner name: David Ridley

Coroner Area: Wiltshire and Swindon

Category: Suicide (from 2015)

This report is being sent to: Department for Business and Trade | Amazon UK | Department for Culture, Media and Sport

The Head of Amazon Legal Department, Amazon UK
The Rt Hon Kemi Badenoch MP, The Secretary of State for Business and Trade
The Rt Hon Lucy Frazer KC MP, The Secretary of State for Culture, Media and Sport  
I am David Ridley, Senior Coroner for Wiltshire and Swindon
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.
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.
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 [REDACTED] 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 [REDACTED]. My investigation will establish how she acquired that digital copy. The book essentially contains instructions on how to make a piece of apparatus [REDACTED] The book also covers other methods again with the aim of end an
individual’s life.
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. [REDACTED]there was also a similar publication
[REDACTED] “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.
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 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 website.
I have raised the concern and ask that both 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.
In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.
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.
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.
9Dated 26th February 2024
Amendment Date 24th April 2024
David Ridley, Senior Coroner for Wiltshire & Swindon