Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0331, written 1 Jul 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Jul 2025 |
|---|---|
| Reference | 2025-0331 |
| Deceased | Barry Spooner |
| Coroner | Nathanael Hartley |
| Coroner area | Nottingham and Nottinghamshire |
| Category | Police related deaths |
| 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 10 July 2023 an inquest was opened into the death of Barry Christopher Spooner, aged 74. The inquest concluded on 17th June 2025. I made a determination at inquest that he died as a result of unlawful killing. 4 CIRCUMSTANCES OF THE DEATH Mr Spooner engaged with the police on 7 occasions between 25 May 2021 and 15 May 2023 following concerns raised by himself, and others, about a female. Concerns included that she was exploiting him for his money in order to buy drugs. Officers who liaised with him for incidents on 27 August 2021, 10 September 2021, 15 October 2021 and 15 May 2023 completed Public Protection Notices (PPNs) and submitted them to the Multi-Agency Safeguarding Hub (MASH). Of those that were submitted, three were referred onwards to Adult Social Care, but that from 15 October 2021 was not. The Probation Service engaged with the female during the same period up until 22 January 2023. I heard evidence about the manner in which she was managed by the probation service. Mr Spooner was exploited financially by the female until his death, and she made efforts to access his bank account, most probably after he had died. He was found in his home address having been murdered by the female. 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: 1 1. Insufficient information sharing from Nottinghamshire Police to the Local Authority in the event of a public protection concern. I heard evidence about the new Vulnerability Policy followed by the police in order to try to improve information sharing between organisations. I was told that when a PPN is completed and sent to the MASH it is considered by an experienced officer who decides whether or not to refer it on to Adult Social Care for their consideration. If they decide not to refer onwards then the officer will consider all PPNs from the previous 12 months. If this review causes them to change their opinion then the current PPN and the previous PPNs will be referred onwards. This ensures Adult Social Care has all relevant information to help them decide upon the best course of action. In accordance with the Vulnerability Policy, it was explained to me that when a PPN is considered suitable for referral to Adult Social Care straight away then previous PPNs are not reviewed and sent on to Adult Social Care if they have not already had them. This means that in a scenario where there have been previous PPNs that have not been provided to Adult Social Care, then that team will not be aware of all of the relevant information when considering the referral from the MASH and the most appropriate course of action. This may impact upon Adult Social Care’s ability to make a proper decision in such cases and may put vulnerable people at more of a risk depending upon whether previous PPNs have been provided to Adult Social Care, or not. 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 26 August, 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. Mr Spooner’s family 2. The Probation Service 3. Nottingham City Council 4. Independent Office of Police Complaints 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: 1 July 2025 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.
Nathaneal Hartley His Majesty’s Assistant Coroner HM Coroner’s Service The Council House Old Market Square Nottingham NG1 2DT 22 August 2025 Dear Sir, Force Headquarters Sherwood Lodge Arnold Nottingham NG5 8PP Re: Regulation 28 Report to Prevent Future Deaths - Barry Spooner I write by way of response to the Regulation 28 report that was issued on 1st July 2025. As a result of the report, your concerns have been discussed with our partner agencies who are integral to information sharing in the context of safeguarding. We will be amending our information sharing processes to address the concerns raised so that in the event that a PPN is considered suitable for referral to adult social care, these will be accompanied by any PPN’s from the previous 12 months which had not previously been deemed suitable for sharing. In order to allow for the logistical aspects of this change to be implemented, this has been agreed to commence from the 1st of October 2025. We hope that this adequately addresses your concern and allows adult social care to make fully informed decisions moving forward. Yours sincerely, Crime, Custody and Criminal Justice
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