Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0710, written 24 Dec 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Dec 2024 |
|---|---|
| Reference | 2024-0710 |
| Deceased | Paul Taylor |
| Coroner | Nathanael Hartley |
| Coroner area | Nottingham and Nottinghamshire |
| Category | Police related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Constable of Nottinghamshire Police 1 CORONER I am Nathanael Hartley, assistant coroner for the coroner area of Nottingham and Nottinghamshire. 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 29th April 2024 an inquest was opened into the death of Paul Ian Taylor, aged 58. The inquest concluded on 17th December 2024. I made a determination at inquest that he died as a result of suicide. 4 CIRCUMSTANCES OF THE DEATH Paul Taylor had been under police investigation for offences that necessitated consideration of the Suicide Prevention and Risk Management of Suspects policy, Nottinghamshire Police document PS260, by the police. That policy was complied with. It was appropriate not to arrest Mr Taylor at the outset of the investigation, so he was voluntarily interviewed and he was released under investigation for a two year period. Within a fortnight of him being made aware that criminal charges had been authorised, he intentionally took a large quantity of prescription medication and was found deceased at his home address on 3 January 2024. 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – When a suspect is arrested for offences requiring a referral to a mental health nurse, commonly referred to in Nottinghamshire as “Liaison and Diversion” the custody sergeant makes that referral automatically, which allows the opportunity for a suspect to obtain assistance from a healthcare professional, if they desire. In addition, there are welfare assessments conducted by the officer in charge of the investigation. In cases where a suspect is interviewed on a voluntary basis for relevant offences, the suspect is not dealt with at a custody suite and a referral to a mental health nurse is 1 not automatic. In this latter scenario, only welfare assessments are completed by the officer in charge of the investigation without any involvement from healthcare services. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have 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 18 February, 2025. 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 Persons: 1. Paul’s family. I have sent a copy of the report to the College of Policing as I believe they may find it useful or of interest. I am under a duty to send the Chief Coroner a copy of your response and all interested persons who, in my opinion, should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she 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 Dated: 24 December 2024 Nathanael Hartley HM Assistant Coroner For Nottingham and Nottinghamshire 2
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.
Ripley Office: Butterley Hall, Ripley, Derbyshire DE5 3RS Notts. Office: Sherwood Lodge, Arnold, Nottinghamshire, NG5 8PP Tel: Fax: Our ref: Your ref: Date: 0300 122 5550 0300 122 7712 Paul Ian Taylor (Deceased) 17.02.2025 HM Assistant Coroner Hartley Coroners Office The Council House Old Market Square Nottingham NG21 2DT Dear Sir, Re: Paul Ian Taylor (Deceased) Thank you for your report dated 24 December 2024 in respect of Paul Ian Taylor pursuant to Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 and paragraph 7, Schedule 5 of the Coroner’s and Justice Act 2009. I reply to the matters you have asked me to consider as follows; When a suspect is arrested for offences requiring a referral to a mental health nurse, commonly referred to in Nottinghamshire as “Liaison and Diversion” the custody sergeant makes that referral automatically, which allows the opportunity for a suspect to obtain assistance from a healthcare professional, if they desire. In addition, there are welfare assessments conducted by the officer in charge of the investigation. In cases where a suspect is interviewed on a voluntary basis for relevant offences, the suspect is not dealt with at a custody suite and a referral to a mental health nurse is not automatic. In this latter scenario, only welfare assessments are completed by the officer in charge of the investigation without any involvement from healthcare services. A policy revision is being undertaken to ensure that the procedures for supporting and safeguarding suspects of relevant offences are consistent, irrespective of whether the individual has been arrested or invited for voluntary attendance. In both scenarios, suspects receive an officer welfare assessment together with an automatic referral to Liaison and Diversion (healthcare services). The amendment to the policy and communication to the organisation will be implemented by 1st March 2025. Yours sincerely, Chief Constable of Nottinghamshire Police
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