Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0467, written 8 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 | 8 Jul 2025 |
|---|---|
| Reference | 2025-0467 |
| Deceased | Peter Ramsden |
| Coroner | Paul Marks |
| Coroner area | City of Kingston Upon Hull and the County of the East Riding of Yorkshire |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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. Secretary of State for the Home Department – 2. Ministry of Housing, Communities and Local Government 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 21st March 2025, I commenced an investigation into the death of Peter Ramsden, aged 74 years. The investigation concluded at the end of the inquest on 26th June 2025. The conclusion of the inquest was: NATURAL CAUSES 4 CIRCUMSTANCES OF THE DEATH Peter Ramsden had a past medical history of hypertension, impaired glucose tolerance, hyperlipidaemia, poor mobility and chronic alcohol excess. He had not been seen for approximately two months by his neighbours who became concerned about his welfare. Entry to his unlocked premises took place on 2nd January 2025 where he was found deceased and in an advanced state of decomposition. There were no suspicious circumstances or third-party involvement surrounding his death. Whilst no named specific disease process can be identified to account for his death, on balance, it was due to a natural disease process. 1 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. – Evidence was heard that there is a lacuna in the law, specifically relating to section 17 of the Police & Criminal Evidence Act 1984 (PACE) which grants police officers the power to enter and search premises without a warrant in specific situations. These include, inter alia, entry for arrest and emergency situations which allows entry to save life or limb or prevent serious damage to a property. In this particular case, evidence was heard that this man had not been seen for two months and there were concerns about his welfare and paramedics attended on one occasion but have no powers of entry. Due to the Right Care, Right Person model, which has been developed over the last few years, the police did not get involved, as it was thought by the concerned individual that this man not being seen was due to a medical problem. Evidence was heard which suggested that on occasions, the ambulance service and the fire service should have powers of entry in the event that a person who is ill, unconscious or otherwise incapacitated, with a remediable disorder, can receive prompt and potentially life-saving treatment. In this case, causation would not have been established as the man has been dead for several weeks, but situations could and will arise where time-sensitive pathological processes require emergency treatment to save life. 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, possibly by considering enhanced powers for the emergency services to enter premises in such circumstances. YOUR RESPONSE 6 7 You are under a duty to respond to this report within 56 days of the date of this report, namely by 12th November 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 Chief Executive Humberside Fire & Rescue; , Chief Executive Yorkshire Ambulance Service; Chief Constable of Humberside Chief Executive UK Ambulance Service . 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 8th July 2025 2
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.
Home Office Prof Paul Marks H.M. Coroner’s Court, The Guildhall Alfred Gelder Street Hull HU1 2AA Dear Professor Marks, Minister of State for Policing and Crime 2 Marsham Street London SW1P4DF www.gov.uk/home-offic e 20 October 2025 Thank you for your letter of 8 August 2025 enclosing a copy of the Regulation 28 Report to Prevent Future Deaths, following the inquest into the death of Peter Ramsden. Please accept my apologies for the delay in responding. I was saddened to learn about the death of Mr Ramsden, and I would first like to express my deepest condolences to his family for their loss. It may help if I outline the ongoing work regarding the Right Care, Right Person (RCRP) approach which is aiming to help ensure the right agencies with the right skills and training respond to people in need of support at the right time. This approach supports police to determine when they should attend a health or social care incident (including mental health), encourages partnership working at a local level and helps prevent criminalisation of people in need. RCRP applies to four areas that police receive requests to deploy resource to, these include: (i) concerns for welfare; (ii) walk outs or people who are AWOL from health settings; (iii) transportation; and (iv) s.136 mental health cases. In these types of incidents, the police will respond where there is a real and immediate risk to life or serious harm, or when responding to a report of crime. Where the threshold is not met, local partners should have in place an agreement on who will respond to different types of situation taking into account local arrangements. It is for partners to work together to determine who will respond to what type of situation and to understand the extent of each partner’s legal powers, they should also have escalation policies in place where attendance cannot be agreed. This is why partnership working is important, to ensure partners are clear on each of their roles and responsibilities to prevent anyone slipping through the gaps which sadly appears to have happened here. Further, RCRP sets a threshold that forces can use to determine if they shall deploy resource, but it does not undermine the independence of Chief Constables and their decisions on how to deploy their resource. As you are aware, section 17 of the Police and Criminal Evidence Act (PACE) 1984 gives police the power to enter a property without a warrant under specific conditions, including to arrest a person for an indictable offence, and to save life or limb or prevent serious harm. The Courts have considered how the power to enter to save life and limb under s.17(e) of PACE should be interpreted. In Syed v Director of Public Prosecutions [2010] EWHC the court opined on the fact that s.17(e) may be used in emergency situations where there is a serious risk of physical bodily injury or harm. However, the court concluded that "concern for welfare is not sufficient to justify an entry within the terms ofs 1 7(1)(e)". The judgment also recognised that Parliament intended the threshold for entry under s.17(1)(e) to be high, reflecting the seriousness of police entering a person’s home without consent. This is separate from the common law doctrine of necessity, which continues to allow other emergency services and members of the public to enter property without permission if it is reasonably necessary to save life or prevent serious harm. It is important to ensure the right balance between the need to enforce the law, ensure public protection and to provide sufficient safeguards and rights to the individual. As with all intrusive police powers, powers of entry must be exercised in a lawful and proportionate way. The Police and Criminal Evidence Act 1984 and the relevant Codes of Practice include safeguards and guidance to the police to exercise such powers fairly, responsibly, without unlawful discrimination, and in line with human rights obligations. I know that ensuring that any learning from reports such as these are considered and implemented is critical. As such, I can advise that a group has been established by the National Police Chiefs Council to review and track any coroner’s reports relating to the application of RCRP. Any learning will be disseminated onward beyond the force in which the incident occurred, and policy amended as needed. Your letter raises issues around powers of entry for Ambulance services and Fire and Rescue services. I believe my officials had previously contacted your office to alert you that this is not within the remit of the Home Office but rather the Ministry of Housing, Communities and Local Government (lead on fire services) and Department for Health and Social Care (lead on paramedics). My officials have brought these matters to the attention of relevant colleagues from those departments. Thank you for writing to me on this important matter. Very best wishes, Minister of State for Policing and Crime
Secretary of State for Housing, Communities &
Local Government
2 Marsham Street
London
SW1P 4DF
Professor Paul Marks
Senior Coroner
Coroner Area of the City of Kingston Upon Hull
and the County of the East Riding of Yorkshire
The Guildhall
Alfred Gelder Street
Hull
HU1 2AA
12 November 2025
Dear Professor Marks,
Thank you for your letter and report dated 08 July 2025 regarding the death of Mr Peter
Ramsden, which was made in accordance with Paragraph 7, Schedule 5, of the Coroners and
Justice Act 2009 and Regulations 28 and 29 of the coroners (Investigations) Regulations 2013.
I am grateful to you for bringing this case to my attention, and for your conduct of the inquest.
First, I want to express my sincere condolences to Mr Ramsden’s family and friends.
RESPONSE
The Government has engaged with the National Fire Chiefs Council as the appropriate body to
provide their opinion on the operational matters relating to this issue.
Concerning the legal position, Fire and Rescue Authorities (FRAs), the legal body overseeing
fire and rescue services, cannot lawfully operate under section 17 of the Police and Criminal
Evidence Act. However, they do possess independent statutory powers of entry under section
44 of the Fire and Rescue Services Act 2004. In the event of an emergency, section 44(1)(c)
and 44(2)(a) of the Act allows authorised FRA personnel to enter premises (by force if
necessary) without the consent of the owner or occupier of the premises or place, if they
reasonably believe entry is needed to protect life or property. Section 58(a) of the Act defines
an ‘emergency’ as an event or situation likely to cause death, serious injury, or serious illness.
This definition, in the opinion of the National Fire Chiefs Council (NFCC) covers emergency
welfare checks where there are reasonable grounds to believe someone may be at risk of death
or serious harm. Sections 11 and 12 of the Act complement section 44 of the Act and provide
(discretionary) powers to respond to events beyond core FRA functions under the Act, when
there is a risk to life, thereby creating the statutory framework for attending incidents in domestic
1
OFFICIAL - SENSITIVE
premises with health partners. These powers can be exercised by an FRA outside as well as
within its area.
In the opinion of the NFCC consideration could also be given to extend such powers to
ambulance services to enable them to make their own entry. This would significantly reduce
the reliance on FRAs and could speed up the process to enable a swifter response to potentially
life-threatening situations.
The NFCC investigated the case of Peter Ramsden with Humberside Fire and Rescue Service.
The Right Care Right Person (RCRP) agreement was used to assess and assign responsibility
of the appropriate agency. While FRAs are not explicitly a part of this National Partnership
Agreement, the NHS Guidance on implementing these states: “If there are significant concerns
about a person and staff cannot gain entry on arrival, then further action should be considered,
for example whether it would be appropriate to apply for a warrant under Section 135 of the
Mental Health Act 1983. Alternatively, in an emergency, the police or fire and rescue service
may need to be contacted (as set out in locally agreed protocols), as they have powers of entry
in certain situations.”
Through these locally agreed protocols, FRAs do assist health partners in gaining entry to
premises where the request falls within the parameters of the Act. This includes supporting
ambulance services where the police involvement threshold has not been met. Humberside
Fire and Rescue Service have informed the NFCC that no assistance was requested during
the paramedics' first attendance on Mr Ramsden despite local protocols being in place.
Following the tragic death of Mr Ramsden, NFCC are working with Humberside Fire and
Rescue Service to ensure that the learning from this tragic incident is shared with other Fire
and Rescue Services via the NFCC Organisational Learning platform.
CONCLUSION
We appreciate the very sad circumstances of the passing of Mr. Ramsden. Whilst in the opinion
of the NFCC and FRAs, a statutory framework exists for FRAs to support the public in tragic
situations like Mr. Ramsden’s, the NFCC suggests there is an argument for an extension of
powers to ambulance services as it would improve speed of response and reduce the burden
on FRAs . I am copying this letter to the Secretary of State at the Department of Health and
Social Care (DHSC) to be aware of the comments concerning rights of access for ambulance
personnel; I have also asked my officials to engage with their counterparts at DHSC on this
topic.
Yours sincerely,
Secretary of State for Housing, Communities & Local Government
OFFICIAL - SENSITIVE
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