Families of the victims are calling for a public inquiry into what they say are the UK government's “repeated failures” to protect vulnerable people from a website promoting suicide.
The Molly Rose Foundation report said departments were warned 65 times about the online forum, which BBC News did not name, and others liked it but took no action.
A suicide prevention charity says at least 133 people have died in the UK as a result of exposure to a toxic chemical promoted by the site and similar forums.
The government did not say whether it would consider an investigation, but said sites must prevent users from accessing illegal content about suicide and self-harm or face “tough enforcement, including significant fines.”
Families and survivors have written to Prime Minister Sir Keir Starmer asking for an investigation to find out why warnings from coroners and campaigners were ignored.
David Parfett, whose son Tom took his own life in 2021, told the BBC that successive governments have offered sympathy but failed to hold them accountable.
“People who create suicide platforms to spread their cult messages that suicide is normal and make money by selling death are still several steps ahead of government ministers and law enforcement,” he said.
“I can’t think of a better memorial for my son than knowing that people like him are protected from harm while they regain their mental health.”
David and six other families are represented by law firm Leigh Day, which also wrote a letter to the Prime Minister expressing its concerns about the main suicide forum.
The letter said the victims were groomed online and were typically in their 20s, with the youngest known victim being 13 years old.
He argues a public inquiry is needed because coroners' courts are failing to make the changes needed to protect vulnerable people.
According to the report, coroners have raised concerns dozens of times and sent repeated warnings to the Home Office, the Department of Science, Innovation and Technology and the Department of Health and Social Care since 2019, when the forum first emerged and was criticized by families.
The report highlighted four main findings:
- The Home Office's refusal to tighten regulation of the substance, which remains easy to obtain online, while the UK Border Force is “struggling to respond to imports” from overseas sellers.
- Media regulator Ofcom's decision to rely on “voluntary measures” by main forum operators rather than taking steps to restrict access in the UK.
- Repeated failures by government departments to respond to coroners' warnings
- Operational shortcomings, including inconsistent welfare checks by police and delays in providing antidotes to emergency services.
A government spokesman said the substance in question was “closely monitored and reported under the Poisons Act”, meaning retailers must tell authorities if they suspect it is being bought with intent to cause harm.
But campaigners say the government's response has been piecemeal and slow, with officials “passing the parcel” rather than taking coordinated action.
Adele Zeynep Walton, whose sister Aimee died in 2022, said families like hers were “ignored and rejected”.
“She was a creative person, a very talented artist and a gifted musician,” she told BBC News.
“Aimee was a hard worker and achieved excellent results at GCSE, but she was shy, quiet and found it difficult to make friends.
“Every time I learn of a new life lost because of the site that killed my sister three years ago, I am furious that another family had to endure this preventable tragedy.”
Demand for investigation follows concerns raised BBC in 2023when an investigation uncovered websites offering instructions and encouragement for suicide and rule evasion.
Andy Burrows, executive director of the Molly Rose Foundation, said the state's inaction “has cost countless lives.”
He also accused Ofcom of being “inexplicably slow” in restricting UK access to the main website, about which the Trust had raised concerns.
According to the Internet Safety Act, which took effect in October 2023, In March 2025, Ofcom was given the power to take action against sites hosting illegal content.which includes assisted suicide. If sites do not confirm they have systems in place to remove illegal material, Ofcom could block them or impose fines of up to £18 million.
UK users are currently unable to access the forum which is located in the US. A post on the forum's homepage said it was blocked from people in the UK not as a result of government action, but because of a “proactive” decision to “protect the platform and its users.”
“We operate under the protection of the First Amendment. However, UK authorities have signaled their intention to enforce their domestic laws on foreign platforms, which could potentially lead to criminal penalties or service disruptions,” it said.
Ofcom said in a statement: “In response to our enforcement action, the online suicide forum has introduced geo-blocking to restrict access by people with UK IP addresses.
“Services that choose to block people in the UK should not encourage or promote ways to circumvent those restrictions.”
He added that the forum remains on a watch list and a previously launched investigation into it remains open while it checks whether the ban is maintained.
- If you or someone you know is affected by mental health problems BBC Action Line I have compiled a list of organizations that can help.
