Prevention of Future Deaths reports · 2025

Peter Ramsden

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 report8 Jul 2025
Reference2025-0467
DeceasedPeter Ramsden
CoronerPaul Marks
Coroner areaCity of Kingston Upon Hull and the County of the East Riding of Yorkshire
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

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

Responses

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.

Response from Home Office (PDF)
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
Response from Housing Communities and Local Government (PDF)
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 

2

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