Isabella Shere: Prevention of future deaths report

Child Death (from 2015)Suicide (from 2015)

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Date of report: 05/05/2024

Ref: 2024-0298

Deceased name: Isabella Shere

Coroner name: Fleur Hallett

Coroner Area: Inner South London

Category: Suicide (from 2015) | Child Death (from 2015)

This report is being sent to: Quora | Department for Culture, Media and Sport | OFCOM

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
 THIS REPORT IS BEING SENT TO:
CEO of Quora,
[REDACTED]The Rt Hon Lucy Fraser KC MP,
The Secretary of State for Culture, Media and Sport
OFCOM
1CORONER  
I am Fleur Hallett, Assistant Coroner, for the Coroner Area of London Inner South
2CORONER’S LEGAL POWERS  
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.
3INVESTIGATION and INQUEST  
On 9 February 2023 an investigation commenced into the death of Isabella Shere, aged 14 years old. The investigation concluded at the end of the inquest on 20 February 2024. The conclusion of the inquest was suicide.

The medical cause of death was 1a Asphyxia caused by 1b Hanging.
4CIRCUMSTANCES OF THE DEATH  
Miss Shere died on 2 February 2023 at her home address in Lewisham, London. [REDACTED]. Her family left the house at around 8 am. Miss Shere was found at 1:21pm and her phone showed a timer which was running at 5 hours and 13 minutes. [REDACTED]. Miss Shere was not known to have been struggling with her mental health but her internet search history in the last four months of her life indicated that she was seeking information relating to methods of ending life. Miss Shere left a note indicating an intention to take her own life.
5CORONER’S CONCERNS  
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you.  

The MATTERS OF CONCERN are as follows.  
There are questions and answers on Quora’s website that provide information [REDACTED]. The question and answer thread that Miss Shere viewed immediately before her death, at the time of writing this report has had 169,700 views.

The content is not marked as adult content when accessed either on a phone or a computer.

Children are able to access the site through search engines without being required to create an account and access content [REDACTED] without being asked if they are an adult or being required to input their date of birth.

When viewing content [REDACTED], a list of related questions is displayed, suggesting further similar content to users and encouraging further consumption of this material.

There is a function to follow questions [REDACTED] encouraging further consumption of this material.

There is an upvoting function which allows users to vote on the most useful answers to questions [REDACTED]. There is pop up question which can appear which asks [REDACTED]. Both of these functions detract from user appreciating the seriousness of the subject matter that is being consumed.

There is not sufficient monitoring and/or moderation of the content of questions/answers in accordance with Quora’s own platform policies. [REDACTED]
6ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action.
7YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by Tuesday 30 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.
8COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to Miss Shere’s parents who are Interested Persons and to the Local Safeguarding Board.
 
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.
9Date 5 March 2024
F.Hallett