Bereaved families and survivors call for public inquiry as report reveals major State failures in response to nihilistic pro-suicide forum

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.

The substance is believed to have cost at least 133 deaths in the UK, but potentially many more.

Law firm Leigh Day has written to the Prime Minister, Prime Minister, Secretary of State for Health & Social Care, Home Secretary and Secretary of State for Science, Innovation and Technology 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.

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.

In addition to the legal letter, the families have also written to Prime Minister Keir Starmer personally 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.”

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, Tomas William Parfett Foundation, The Center for Countering Digital Hate and The Jordan Legacy.

Lives lost

Below are the loved ones of seven bereaved families Leigh Day represents.

Hannah Aitken

Hannah, from Surrey, died age 22 on 14 September 2023.

Hannah was a much loved daughter and sister. She was bright, kind and caring, known for her beautiful smile and deep blue eyes. Hannah had a diagnosis of autism and had struggled with her mental health since age 12. Over a 5 year period from 2017 Hannah was admitted to seven different mental health hospitals for treatment at various times. At the time of her death she lived in a flat in Caterham supported 24/7 by staff, and received ongoing care and treatment from mental health services. Hannah ordered the poisonous substance online to her flat from abroad. Hannah’s family believe she found out about the substance and its use in suicide through the suicide forum.

An inquest was held into Hannah’s death and concluded in November 2024. The coroner heard evidence from the Home Office, who were designated as an Interested Person in the inquest, about the system of regulation of the poisonous substance. The Home Office gave evidence that the Poisons Act is focused solely on the prevention of terrorism and there is no system of regulation of the poisonous substance to address the risk of suicide and self-harm. The coroner also heard evidence that there is no system of regulation at all for imports of the poison from abroad. Several ambulance bodies also gave evidence to the inquest and explained that while a highly effective antidote to the substance exists, it is carried by almost no UK ambulance services.

The Assistant Coroner in Surrey said in her findings and conclusion that ownership needed to be taken by government departments to address the risk of suicide and self-harm from the substance, and that its “dangerous availability” is an ongoing concern. The Coroner sent a Prevention of Future Death report to the Home Office and Department of Health and Social Care raising her concerns.

The same seller of the substance has since been linked to at least one other death in the UK.

Vlad Caisley

Vlad, from Southampton, died aged 17, on 7 May 2024.

Vlad was a much loved son, brother and grandson and great grandson. Vlad had been diagnosed with Autism and depression, but shortly before his death enjoyed a holiday with his sibling. Unbeknownst to the family prior to this death Vlad was active on an easily accessible suicide forum where it is believed he found details of where to purchase and how to use the substance. Vlad obtained two packages of the substance, from suppliers in Ukraine and in Poland.

The inquest into Vlad’s death is ongoing and a 29 year old woman from London was arrested last year suspected of encouraging or assisting the suicide of another.

Grace Nevens

Grace, from Morpeth, died aged 22 on 4 November 2024.

Grace was a much loved daughter, sister, girlfriend, granddaughter, niece, cousin and friend. She was a kind, caring soul who helped others while struggling with her own mental health.

Grace died having ingested a substance which she purchased online. Anti sickness medication was also found next to Grace. Her parents found transactions on Grace’s bank statements which identified Grace had purchased the substance online from a supplier in Ukraine. It is known that the suicide forum hosted a guide to taking the substance which included using anti-sickness medication however the extent of Grace’s online activity related to suicide is currently unknown.

The inquest into Grace’s death is currently listed to take place on 9 December 2025.

Imogen Nunn

Immy, from Bognor Regis, died age 25 on 1 January 2023 in Brighton.

Immy was a much loved daughter, sister and friend. She was gentle, kind and caring, known for being to make anyone she was around feel special. She had a loyal and huge following on TikTok where she was popular for her warm and relatable videos about her mental health and being deaf.

Immy had struggled with her mental health since age 14 and spent several prolonged periods as an inpatient in mental health hospitals. She had a diagnosis of complex PTSD and emotionally unstable personality disorder and at the time of her death was receiving ongoing care and treatment from NHS mental health teams and support workers. In the months before her death when her mental health was deteriorating, Immy told her mental health team that she had been accessing a suicide forum and had purchased a substance online. Despite Immy’s efforts to get the support she needed, she died after taking the substance at her home. Police later found she had purchased the substance from Kenneth Law, who is currently facing trial in Canada and linked to 99 deaths in the UK.

An inquest into Immy’s death was held in March and May 2025. The senior coroner in Sussex found several failings in Immy’s care by mental health professionals, including that a failure to put in place safeguarding measures following her disclosures about the suicide forum and substance contributed to her death.

Tom Parfett

Tom, from Berkshire, died aged 22 in October 2021.

Tom was a much loved son and brother, who was diagnosed as on the Autistic Spectrum at age 13. Tom had an incredible ability to build and maintain strong friendships with a great sense of humour, and was studying at St Andrews University.

Tom was found dead in a hotel on 28 October 2021 having ingested a substance. After his death his father researched the substance and found what he believes are Tom’s posts (and posts about Tom) on a suicide forum. On the forum he found details of whether to buy the substance at a high level of purity, instructions on how to use it and other examples of encouraging and assisting suicide. It is now known that the substance was supplied to Tom (and also to his father after Tom’s death) from Kenneth Law, who is currently facing trial in Canada and linked to 99 deaths in the UK.

The inquest into Tom’s death is currently part-heard and further information is awaited from the Coroner.

Aimee Walton

Aimee, from Southampton, died aged 21 in October 2022.

Aimee was a much loved daughter and sister. She was creative, a very talented artist, gifted musician and a huge Pharrell Williams fan. She played the piano, saxophone and harmonica, and as a teenager wrote music. Aimee was hardworking and achieved great GCSE results, however she was shy and quiet and struggled to make friends. Aimee was also neurodivergent.

Aimee was found dead in a hotel room with a third party, unknown to Aimee’s family, present. Aimee had died after ingesting a substance which her family now understand was supplied by Kenneth Law, who is currently facing trial in Canada and linked to 99 deaths in the UK. Aimee’s family learnt after her death that Aimee was active on a suicide forum, including posting on a thread where people appeared to be looking for ‘partners’ to end their life with, or assist with ending life.

The inquest into Aimee’s death is currently suspended.

Beth Langton

Beth, from Nottingham, died aged 22 on 18 February 2023.

Beth was a funny, loving, loyal and intelligent daughter, sister, stepsister, granddaughter, niece and friend, who made delicious brownies and a cracking millionaire shortbread. Beth experienced trauma at a young age and despite struggling with her mental health from 12 years old, she did well at school and secured an apprenticeship to become a pharmacy technician, which she had enjoyed greatly. At the time of her death was living in supported accommodation, where her physical environment was subject to many restrictions to help keep Beth safe. Despite this Beth was able to receive a delivery of the substance that ended her life, and Beth’s phone showed she had viewed a guide about using the substance to end life on a suicide forum. Beth purchased the substance from an English company.

The inquest into Beth’s death took place in July 2024 and the Coroner found multiple failings in the care provided to Beth, leaving Beth feeling abandoned and contributing to her death. The Coroner issued a Prevention of Future Death report in relation to the substance and the forum: Bethany Langton: Prevention of Future Deaths Report - Courts and Tribunals Judiciary.