Prevention of Future Deaths reports · 2024

William Helstrip

Regulation 28 report to prevent future deaths, reference 2024-0030, written 19 Jan 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report19 Jan 2024
Reference2024-0030
DeceasedWilliam Helstrip
CoronerPaul Marks
Coroner areaEast Riding and Hull
CategoryAlcohol, drug and medication related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

ANNEX A 

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS (1) 

NOTE: This form is to be used after an inquest. 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO:  

1. 

, Chief Constable of Humberside Police 

1 

CORONER 

I am Professor Paul Marks, Senior Coroner, for the Coroner Area of City of Kingston 
Upon Hull and the County of the East Riding of Yorkshire. 

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 30th September 2022 I commenced an investigation into the death of William Steven 
Helstrip, aged 18 years. The investigation concluded at the end of the inquest on 8th 
January 2024. The conclusion of the inquest was: ACCIDENT 

4 

CIRCUMSTANCES OF THE DEATH 

These are set out in my summary and findings of facts which are attached. 

William Steven HELSTRIP was found deceased at 5 James Court, Kirkgate, 
Pocklington, East Riding of Yorkshire on the 26th of May 2022. He died from the 
combined effects of various drugs including 
 which he had 
sourced from the internet. The drugs led to cardiorespiratory depression and death. 

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 5 

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.  –  
The Deceased’s parents informed the attending police officer that Mr Helstrip had been 
buying drugs from the “Dark Web” and that packages containing these drugs had been 
sent, recorded delivery, via Royal Mail to his premises. Despite this, the police 
investigation concluded that there were no suspicious circumstances or third-party 
involvement surrounding Mr Helstrip’s death and hence no criminal investigation took 
place. This was based on the attending officer’s impression, which did not appear to 
take into consideration the information about the sourcing and method of delivery of the 
drugs. Subsequently, Mr Helstrip’s parents contacted the then Chief Constable of 
Humberside Police, in 2023 informing him of their concerns about the lack of 
investigation on the part of the police. A senior investigating officer was then allocated to 
the case, who looked at the issue of illicit drugs being sent via Royal Mail, by recorded 
delivery, to see whether the vendor of these substances could be identified and help 
police with their inquiries. Evidence was heard from this detective, that whilst the 
investigation is still on-going, time sensitive evidence in the form of CCTV footage from 
the post office from whence the package was sent, is irretrievably lost, and that this has 
compromised the identification of the suspect. 

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you and your 
organisation has 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 by Friday 15th March 2024. 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 
Person: 
copy to 

, Police and Crime Commissioner for Humberside. 

 Mr William Helstrip’s parents. I am also sending a 

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 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. 

9 

19th January 2024                                        

2

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Humberside Police (PDF)
NOT PROTECTIVELY MARKED 

HUMBERSIDE POLICE 
Police Headquarters 
Priory Road 
Hull 
HU5 5SF 

Professor Paul Marks 
Senior Coroner for Hull and the East Riding  
The Guildhall 
Alfred Gelder Street 
Hull  
HU1 2AA 

15th March 2024 

For the Attention of Professor Paul Marks 

Dear Coroner 

Inquest touching on the death of William Steven Helstrip 

I write in response to the Regulation 28 report in the above matter, issued on 19 January 2024 
and received by Humberside Police on 22 January 2024. 

I  am  aware  of  the  circumstances  of  Mr  Helstrip’s  death  and  first  wish  to  offer  my  sincere 
condolences to his family for their sad loss. 

Your report raised the following matters of concern: 

The Deceased’s parents informed the attending police officer that Mr Helstrip had been buying 
drugs from the “Dark Web” and that packages containing these drugs had been sent, recorded 
delivery, via Royal Mail to his premises. Despite this, the police investigation concluded that 
there were no suspicious circumstances or third-party involvement surrounding Mr Helstrip’s 
death and hence no criminal investigation took place. This was based on the attending officer’s 
impression, which did not appear to take into consideration the information about the sourcing 
and method of delivery of the drugs. Subsequently, Mr Helstrip’s parents contacted the then 
Chief Constable of Humberside Police, in 2023 informing him of their concerns about the lack 
of investigation on the part of the police. A senior investigating officer was then allocated to 
the case, who looked at the issue of illicit drugs being sent via Royal Mail, by recorded delivery, 
to see whether the vendor of these substances could be identified and help police with their 
inquiries. Evidence was heard from this detective, that whilst the investigation is still on-going, 
time  sensitive  evidence  in  the form  of  CCTV  footage  from the  post  office  from  whence  the 
package was sent, is irretrievably lost, and that this has compromised the identification of the 
suspect. 

Web site:  www.humberside.police.uk 

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Response to matters of concern 

Following the conclusion of the inquest and upon receipt of your report, a Senior Investigating 
Officer was appointed to carry out a full and thorough investigation review in order to identify 
any learning for the Force. As part of this review, almost all of the individuals have been de-
briefed  regarding  this  case.  One  individual  has  not  been  available  to  speak  with  as  yet, 
attempts are ongoing to arrange a time when we can conduct a debrief. 

The  investigation  review  found  that  the  officer  in  the  case  (OIC)  was  cognisant  of  the 
information provided by Mr Helstrip’s family that it was possible Mr Helstrip had obtained drugs 
from the internet and in particular the dark web. The OIC acted upon this information as he 
seized packaging and invoices of the various drugs/supplements found on the day Mr Helstrip 
was discovered deceased. It is worth noting that the identification of the substances purchased 
online by Mr Helstrip prior to death were not at that time illegal, however since then legislation 
has changed and they would now be a controlled substance.  

The investigation review identified a lack of knowledge and understanding by OICs in relation 
to Coroners enquiries and that fast-track actions may be conducted without waiting for a formal 
request from the Coroner to prevent evidence loss.  

The review further noted that Detective Inspectors (DI), as part of their core duty role, attend 
sudden  and  unexpected  deaths  to  ensure  the  scene  is  assessed,  raise  any  suspicious 
circumstances  to  the  dedicated  Senior  Investigating  Officer  and  to  provide  advice  around 
immediate enquiries, setting the direction and tone for the investigation. However, DI’s do not 
then have any ongoing supervision in most deaths they attend, beyond their initial attendance. 
This is because the DI’s who attend these deaths generally have responsibility for overseeing 
all force investigations during that period of cover and do so on the understanding that any 
ongoing investigation will be managed by the OIC. We acknowledge that there is therefore a 
potential for a lack of supervision, direction and review of OICs investigations and that there 
needs to be a clear policy of handover to the incoming OIC’s Detective Inspector. 

The review has made the following learning recommendations: 

1.  An  intranet  page  or  resource  centre  to  provide  OICs  with  knowledge  and 

understanding or requirements in relation to Coroners enquiries.  

2.  Fast-track actions and Golden Hour Principles to be refreshed during CPD sessions 
for Patrol PC’s and Sergeants. Officers need to be directed to conduct critical enquiries 
at the point of first attendance and not wait for a formal request to prevent evidence 
loss.  

3.  Review of sudden and unexpected death policy – with an amendment regarding drug 
related deaths and advice given to follow lines of enquiry where a drug is believed to 
have been posted through a recordable means.  

4.  Inspectors  to  be  briefed  regarding  their  responsibility  around  the  direction  of 

investigations and lessons learned from this investigation. 

5.  A  review  of  the  Coroners  Investigations  process  and  for  a  policy  to  be  formulated 
regarding  the  allocation  and  further  investigation  of  coronial  matters  investigations. 
This is to include oversight by the Detective Inspectors and if this period need to be 
extended to cover more than initial attendance.  

The current timescales for the above recommendations implementation and action is yet to 
be  determined.  However,  we  are  taking  the  recommendations  very  seriously  and  work  is 
ongoing  at  this  moment  in  time  to  ensure  all  are  completed  without  undue  delay.  For 

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reassurance, the Force will write to you again once the various recommendations have been 
fully implemented.   

I hope that this provides you with assurance that the matters of concern that were identified 
are being fully addressed by Humberside Police and I thank you for bringing these matters to 
my attention.  

Yours sincerely 

Chief Constable 

3 

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