Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0334, written 4 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 | 4 Jul 2025 |
|---|---|
| Reference | 2025-0334 |
| Deceased | Daniel Hatchett |
| Coroner | Nadia Persaud |
| Coroner area | East London |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
MISS N PERSAUD
HIS MAJESTY’S CORONER
EAST LONDON
EAST LONDON CORONERS, 124 Queens Road, Walthamstow, London E17 8QP
Telephone 020 8496 5000 Email coroners@walthamforest.gov.uk
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
Ref:
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Department of Health & Social Care:
Clinical Effectiveness Group, Queen Mary’s University of London
Sent via email:
1
CORONER
I am Nadia Persaud, Area Coroner for the coroner area of East London
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On the 6 January 2025 I commenced an investigation into the death of Daniel Norman
Hatchett, aged 64 at the time of his death. The investigation concluded at the end of
the inquest on 26 June 2025 with a conclusion of suicide.
4
CIRCUMSTANCES OF THE DEATH
Mr. Daniel Hatchett had no history of mental health diagnoses. In the last few years of
his life he suffered a decline in his physical health (most notably due to dilated
cardiomyopathy, chronic kidney disease and atrial fibrillation), which together with
1
work stresses caused a decline in his mental health. He attended a holistic BUPA
assessment in December 2023. The BUPA report highlighted stress levels and a new
diagnosis of atrial fibrillation which required prompt attention. Both health concerns
were reported to Mr. Hatchett's general practitioner. In response to the BUPA report,
Mr. Hatchett's GP directed him to A&E to obtain urgent treatment for the atrial
fibrillation. Treatment was provided by the A&E team in the form of anticoagulation.
The GP surgery did not action the recommendation for primary care psychotherapy
and/or follow-up of his mental health to address his levels of stress. Mr. Hatchett did
not present to any of the healthcare professionals as being at risk of suicide or at risk
of deliberate self-harm, but he was not expressly questioned about his mental health.
There was a missed opportunity to refer him for therapy in January 2024 and/or for
the GP to follow up on Mr. Hatchett's mental health. It is not possible to conclude on
the balance of probabilities that this would have prevented his death in November
2024. In the very early hours of the 9 November 2024 Mr. Hatchett was discovered
hanging in his home address. Paramedics attended and pronounced his life extinct on
scene. Police attended, investigated and deemed the circumstances as non-
suspicious.
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. Patients with chronic disease often present with concomitant mental health
decline.
2. GP appointment timings are often insufficient for the necessary holistic review
of this cohort of patients.
3. Templates for GPs, to assist them in reviewing patients with chronic disease,
do not include a section for review of mental health. It was considered that
such a requirement could assist in identifying patients whose mental health
has been adversely affected by declining physical health. This would allow
the opportunity for necessary mental health support to be offered to these
patients.
4. The inquest heard that it is well known that middle aged men infrequently
open up to their GP to express concerns about their mental health. An
express question on a chronic disease review could help to elicit concerns
that would otherwise remain undiscovered.
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 31 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 am sending a copy of my report to the Chief Coroner, to the family of Mr Hatchett, to
the CQC, to the local Director for Public Health and to Mr Hatchett’s general
practitioner.
2
I am also under a duty to send a copy of your response to the Chief Coroner and all
interested persons who in my opinion should receive it.
I may also send a copy of your response to any other 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. 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.
9
4 July 2025
3
2 responses 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.
Minister of State for Care 39 Victoria Street London SW1H 0EU HM Coroner Nadia Persaud 124 Queens Road Walthamstow E17 8QP 27 October 2025 Dear Ms Persaud, Thank you for the Regulation 28 report of 4th July 2025 sent to the Department of Health and Social Care about the death of Mr Daniel Norman Hatchett. I am replying as the Minister of State for Care, responsible for primary care and general practice. Firstly, I would like to express how saddened I was to read about the circumstances surrounding Mr. Hatchett’s death, and I extend my sincere condolences to his family and loved ones. The circumstances outlined in your report are concerning, and I am grateful to you for bringing these matters to my attention. I recognise that, following the treatment of his heart condition, Mr. Hatchett’s mental health needs were not appropriately addressed, and there was a clear missed opportunity to offer Mr Hatchett essential support. Your report raises concerns regarding the lack of adequate consideration and structured support for the mental health needs of patients with chronic physical conditions. In preparing this response, Departmental officials have made enquiries with NHS England and Mr Hatchett’s general practice to ensure that your concerns are properly addressed. I understand the significant impact that living with a long-term condition can have on a person’s mental health. To address this, NHS Talking Therapies Long Term Conditions services provide evidence-based psychological therapies for people with depression and anxiety disorders, who also have a long-term physical health condition. These services are designed to ensure that mental health needs are recognised and treated as part of overall care for those with chronic conditions. All Integrated Care Boards (ICBs) are now also expected to expand local provision by commissioning NHS Talking Therapies services that are integrated into physical healthcare pathways, ensuring that people with long-term conditions can access timely and appropriate mental health support alongside their physical care. Additionally, anyone in England experiencing a mental health crisis can speak to a trained NHS professional at any time of the day by calling 111. Trained NHS staff will assess patients over the phone and guide callers with next steps. I recognise and agree that early identification of undiagnosed anxiety and depression in individuals with long-term conditions is imperative. The Long-Term Conditions template used by GPs during patient reviews includes specific sections designed to screen for symptoms of anxiety and depression. Within the template, there is a dedicated tab for completing validated screening tools, namely, the PHQ-9 and GAD-7 questionnaires. These have been incorporated into the template for several years, in recognition of the fact that patients living with chronic diseases are at increased risk of experiencing associated mental health difficulties. This tab appears for all patients, regardless of any prior mental health history, to allow for opportunistic screening and early identification of emerging symptoms of anxiety or depression. As clinical professionals, we expect that GPs conduct their appointments with sufficient time to address their patients’ needs and to appropriately assess any health concerns. General Practices are independent businesses and are therefore responsible for the way they operate, including the duration of individual appointments. This framework allows GPs to appropriately identify both physical and mental health issues, ensure thorough assessment, and provide timely interventions or referrals where necessary. I know how important it is that we understand the challenges that men face in seeking help so we can ensure that the care they receive meets their needs. We launched a 12 week call for evidence in April 2025, asking men of all ages to come forward and feed into England’s first ever men’s health strategy. This was the crucial first step in understanding what works and what doesn’t and how we can design services men will actually use. The call for evidence closed on 17 July 2025 and we are now analysing responses to inform the development of our strategy. Mr Hatchett's general practice has provided the following contribution in response to your report: As a practice, we will now send out the Waltham Forest Talking therapy (IAPT) website details and phone number to all of our patients with chronic diseases, and with stress, so they are sign-posted to seek help. We have also reflected that during a 10-to-15-minute appointment, unless the patient tells the practitioner about their stress and low mood, or if their demeanour body language indicate they have mental health troubles, it is difficult to be proactive about seeking this aspect of their health out, amidst all the other health needs being addressed. As clinicians we will aim to do better and ask open-ended questions about alcohol use, stress and low mood as much as possible but we realise the time constraints on us means we often rely on the patient & families to alert us about these problems. We have learnt that we cannot make assumptions that someone is mentally well by their appearance, and we will ask more questions about mental health and seek out those who need more help when they have physical health problems. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely,
Clinical Effectiveness Group (CEG) Queen Mary University of London 3rd Floor, Abernethy Building, Newark Street, London, E1 2AT qmul.ac.uk/ceg Incorporated by Royal Charter as Queen Mary University of London
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