Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0003, written 4 Jan 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Jan 2016 |
|---|---|
| Reference | 2016-0003 |
| Deceased | Mark Holdsworth |
| Coroner | Richard Marshall |
| Coroner area | Lincolnshire (Central) |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
HM CORONER Central Lincolnshire REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Constable Neil Rhodes, Lincolnshire Police CORONER | am Richard Marshall,, Assistant Coroner, for the area of Central Lincolnshire, Lindum House, 10 Queen Street, Spilsby, Lincolnshire, PE23 5JE. CORONER’S LEGAL POWERS | 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 4"" February 2015 an investigation was commenced into the death of Mark Anthony Holdsworth, aged 35 years at the time of his death. The investigation concluded at the Inquest on 10" December 2015. | returned a conclusion of 'Took his life’. The medical cause of death was: 1a. Multiple Injuries CIRCUMSTANCES OF THE DEATH The deceased was released from Police Custody at Lincoln Police station at 00.26 hrs on 23/01/2015 following an allegation under the Sexual Offences Act 2003. He was collected bya family member and taken to his car as he wished to have a drive around. At 04.37 hrs the same morning he was laid on the train line between Lincoln and Doncaster when he was struck bya freight train. The death was confirmed by attending paramedics. CORONER’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 will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — Mark Anthony Holdsworth w: the Police on 23 January 2015 on suspicion of rape of his 14 year old step daughte He committed suicide in the early hours on 24" January 2015 shortly after being released from custody on police bail. Shortly prior to his arrest, other officers took th; i r mother to Spring Lodge for an ABE/VW1 interview. On route i Mother told the officers that Mr Holdsworth had said he would 'kill himself if released’ This information was, | am told, later added to the incident log but was not drawn to the attention of either the arresting officers or the custody staff or Custody Sergeant. 1 There is not criticism of the risk assessment procedure undertaken by the custody staff when Mr Holdsworth was booked in at Lincoln station but it's clear that they lacked the significant information that Mr Holdsworth had very recently threatened to kill himself. | am not sure what time the incident log was updated (I have not seen it) but | appreciate that it is impractible to suggest that custody staff examine incident logs regularly because of the pressure of time and work. ACTION SHOULD BE TAKEN | am therefore making a recommendation in the following terms: Where Police Officers involved in the investigation of an offence become aware of suicide or serious self-harm by the principal suspect, they should (if they are not themselves involved in the arrest of the suspect) notify the arresting officer(s) and/or the relevant Custody Sergeant of that fact as soon as reasonably practicable. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 29" February 2016. 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons a) The family of Mr Holdsworth | 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. H.M Assistant Coroner, Central Lincolnshire
See every Prevention of Future Deaths report matching Richard Marshall, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.