Miranda Avanzi: Prevention of Future Deaths Report
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Date of report: 14/11/2024
Ref: 2024-0626
Deceased name: Miranda Avanzi
Coroners name: Ian Potter
Coroners Area: Inner North London
Category: Suicide (from 2015)
This report is being sent to: OFCOM | Department for Culture, Media and Sport
| Regulation 28 Report to Prevent Future Deaths | |
|---|---|
 THIS REPORT IS BEING SENT TO: 1. [REDACTED] Chief Executive Ofcom Riverside House 2a Southwark Bridge Road London SE1 9HA 2. [REDACTED] Secretary of State for Culture, Media and Sport 100 Parliament Street London SW1A 2BQ | |
| 1 | CORONER I am Ian Potter, assistant coroner for Inner North London |
| 2 | CORONER’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. |
| 3 | INVESTIGATION and INQUEST On 18 July 2024, an investigation was commenced into the death of Miranda Emilia AVANZI, aged 58 years at the time of her death. The investigation concluded at the end of an inquest on 12 November 2024. The conclusion of the inquest was ‘suicide’. The medical cause of death was: 1a suspension by ligature |
| 4 | CIRCUMSTANCES OF THE DEATH On 9 July 2024, Miranda Avanzi was found unresponsive at her home address, partially suspended by a ligature [REDACTED]. Her death was verified by a paramedic shortly thereafter. Ms Avanti left notes of intent, clearly indicating a settled intention to end her own life, and instructions that she should not be resuscitated. |
| 5 | CORONER’S CONCERNS During the course of my investigation and 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: The police found a printout from a blog post close to Ms Avanzi, while investigating the initial circumstances of her death. That 10-page document contains a step-by-step guide (with the inclusion of pictures and diagrams) on how to ‘succeed’ in ending one’s life by ‘partial hanging’. It was clear that this guide had been followed in the circumstances of this case. While it is not obvious which website or forum this particular guide came from, it does cite numerous sources including ‘[REDACTED]’ and ‘[REDACTED]’. Just a basic search on Google or other search engines, reveals a significant number of forums and blogs, where users are able to obtain all manner of guides to completing suicide. Many of these sites have no, or no useful requirement for any type of age verification. The search engine suggests, at the top of the page, that help is available by dialling 999, which would appear to be an acknowledgement that the content resulting from the search is likely to be concerning and that person undertaking the search is likely already highly vulnerable. I am concerned that the ready availability of such information, that provides clear instructions and advice for individuals wanting to end their own life at their own hands is of the utmost concern. |
| 6 | ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 9 January 2025. 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. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Ms Avanzi. 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 completed or redacted or summary form. She may send a copy of this report to any person who she 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. |
| 9 | Ian Potter HM Assistant Coroner, Inner North London 14 November 2024 |