Prevention of Future Deaths reports · 2024

Paul Taylor

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 report24 Dec 2024
Reference2024-0710
DeceasedPaul Taylor
CoronerNathanael Hartley
Coroner areaNottingham and Nottinghamshire
CategoryPolice related deaths · Suicide (from 2015)
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

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 Nottinghamshire Police (PDF)
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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