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British authorities failed to act on multiple official warnings about a website promoting suicide that has been connected to at least 50 UK deaths, the BBC has found.
The online forum, which we are not naming, is easily accessible to anyone on the open web, including children.
Our investigation has identified multiple warnings to government by coroners and a number of police investigations, but the forum still remains active.
Families of the dead, the youngest just 17, say the failure to act led to more avoidable deaths. They are demanding an inquiry.
They’re speaking out, despite the risks others may find the forum, because they want action now to shut it down and prevent deaths in the future.
The forum’s founders remain elusive, but during our investigation we managed to track one of them down to his home in the US.
The government was first warned by a coroner about the forum in December 2019.
Callie Lewis had been assessed as being autistic at a young age and struggled with chronic depression and suicidal thoughts.
Callie spent just over a month as a forum member. She researched a new suicide method and bought materials which she later used to end her life.
“Without those forums, I think my daughter would have struggled to find the information that she was looking for about how to die,” Callie’s mother Sarah told the BBC at the time.
The inquest into Callie’s death highlighted the role the forum had played.
After an inquest, coroners have a duty to ask public bodies, companies and individuals to explain what steps they plan to take to prevent a similar death taking place in the future.
This is called a Prevention of Future Death report. However, it is advisory only, and doesn’t lay down what action should be taken.
The senior coroner in charge in Central and SE Kent, Patricia Harding, wrote to the Department for Culture, Media and Sport, raising concerns.
“Callie was enabled by the advice provided through the forum to frustrate a mental health assessment and thereafter take her life,” Ms Harding wrote.
“In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action.”
50 UK deaths
We have discovered that at least six coroners have written to government departments demanding action to shut the forum down.
Collating inquest reports, press articles and posts on the forum itself, we have identified at least 50 UK victims.
We have learned that at least five police forces are aware of the forum, and have investigated deaths linked to it, but have been unable to take action.
The forum is hosted abroad and is well known among those struggling with depression and suicidal thoughts. It has more than 40,000 members worldwide. More than two million messages have been posted, many of them horrifyingly graphic.
Only last month, a post on the forum showed an image of a package that arrived by courier, apparently poison, ordered by a child in another country.
“It arrived while I was at school,” they wrote. “I called my mum and told her not to open it. I’m going to use it today.”
Another user posted a photograph of his hotel bedroom, with equipment set up ready for a suicide attempt.
Other forum members offer encouragement to these kinds of posts.
“Good luck. I hope it works out well and you go peacefully,” writes one user. “Godspeed,” says another.
The problem for the authorities is that the website is hosted anonymously and no-one knows who is currently running it.
But the BBC did manage to track down one of those who created it.
Lamarcus Small helped set up the forum after a similar pro-suicide thread was banned from the social media forum and discussion site Reddit.
Small lives in the suburbs of Huntsville, a city in the US state of Alabama. Something of a recluse, he rarely comes out of his house.
We waited three days to speak to him.
Small has claimed in the past to no longer be involved in the forum. When confronted, he refused to answer any of our questions.
Families hold Small responsible for hundreds of deaths worldwide.
23-year-old Joe Nihill from Leeds found the forum in April 2020.
Joe spent a month online, exchanging messages from other forum users, being coached on the most effective way to die.
Joe even left a note to his family, spelling out how dangerous the forum had been for him. “Please do your best to close that website for anyone else,” he wrote.
“The government are failing people. The police are failing people” says Joe’s sister-in-law Melanie.
“It’s a joke,” interjects Joe’s mother Catherine. “The government knew about this five years ago. Why are we still here? Are we supposed to just leave this and let them continue?”
Joe’s death prompted another coroner’s letter.
Kevin McLoughlin, Senior Coroner for West Yorkshire (East) wrote to the Department of Health & Social Care (DHSC).
The forum, he said, “may be actively promoting a particular method of committing suicide and hence breaking the criminal law by assisting suicide. Consideration should be given to blocking its availability in the UK so as to negate this risk”.
The families of those who’ve died want to know why more hasn’t been done.
Imogen Nunn was a deaf mental health campaigner who had hundreds of thousands of followers on TikTok.
But despite her positive messages on social media, “Deaf Immy” as she was known, continued to struggle with her own mental health.
She found the forum in November 2022 and ended her life three months later.
Her mother Louise told us: “When will something be done about it, how many lives have got to be lost?”
Lee Cooper, whose brother Gary found the forum and took his own life last July, said: “If it was shut down five years ago, hundreds of people would still be alive. If it was shut down a year ago, my brother would still be alive.”
The forum also received attention from police in the UK after the death of 22-year-old Tom Parfett – in Surrey in October 2021.
Tom had bought poison from Kenneth Law, a well-known Canadian seller whose details were widely shared on the forum.
When Law was arrested in May this year, Canadian police discovered that he had shipped the same poison to hundreds of buyers around the world.
He is now awaiting trial, facing multiple charges of counselling or aiding suicide.
Counting the human cost
Welfare checks were carried out, coordinated by the UK’s National Crime Agency. It confirmed that 88 people had died in the UK alone.
Our research suggests almost all the 88 probably found Kenneth Law through the same online forum.
There is likely to be considerable overlap with the 50 we have positively identified, who we know used the site, but didn’t necessarily buy from Law.
We even found one of the forum’s administrators advising users on how to evade welfare checks by police looking for poison shipped by Law.
“Don’t put it in plain sight,” they wrote. “Don’t let them into your house without a search warrant. You don’t need to talk to the police.”
While Law’s own websites have been removed, the forum remains up – and users can now find details of alternative suppliers and suicide methods.
The National Crime Agency has begun an investigation into Law to see if any criminal offences have been committed in the UK.
The Agency has said it will “explore every avenue” and has not ruled out looking into the forum too.
New criminal offences
The UK government says that the Online Safety Bill, due to receive royal assent shortly, should address many of these issues.
When it becomes law, the Online Safety Act will include a new criminal offence of encouraging self harm and force platforms to remove that kind of content when it is reported to them.
The DHSC told us it has pledged to reduce England’s suicide rate within two and a half years with a new national suicide prevention strategy, “backed by more than 100 measures including a national alert system”.
The Samaritans told us the act should go some way to improve safety. However, Jacqui Morrissey from the mental health charity has misgivings.
“It fails to reach its full potential to save lives,” she says. “Dangerous suicide and self-harm content will continue to be accessible to anyone over the age of 18.”
Tom Parfett’s father David is also sceptical.
“I don’t believe the Online Safety Bill will resolve this problem,” he said. “It’s too weak. It will not lead to change. And consequently, people will still be dying.”
The suicide forum recently added an announcement to its front page which says: “We will not be following or complying with the Online Safety Bill which was recently signed into law in the UK. The bill will not affect the operations of the site.”
Another post says: “All future censorship demands from any foreign government will be ignored or blocked. We do not answer to any foreign governments’ demands for censorship.”
Ofcom – which will take on the role of digital regulator once the act becomes law – says it would be a serious concern if companies say they are going to ignore the law, and adds that it will have a “broad range of enforcement powers”.
Sites and apps will have to take steps to stop users from coming across illegal material, and Ofcom says that platforms will have to “act swiftly to remove these kinds of videos or posts when they become aware of them”.