Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0491, written 2 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Oct 2025 |
|---|---|
| Reference | 2025-0491 |
| Deceased | Georgia Barter |
| Coroner | Dr Shirley Radcliffe |
| Coroner area | East London |
| Category | Community health care and emergency services 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.
DR SHIRLEY RADCLIFFE HIS MAJESTY’S CORONER EAST LONDON 124 Queens Road Walthamstow, E17 8QP REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Department , Secretary of State for the Home 1 CORONER I am Dr Shirley Radcliffe assstant 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 7th May 2020 this Court commenced an investigation into the death of Georgia Jay Barter aged 32 years. The investigation concluded at the end of the inquest on 2nd October 2025. The conclusion of the inquest was unlawful killing. Cause of death was: 1a multi organ failure 1b liver toxicity 1c paracetamol overdose 4 CIRCUMSTANCES OF THE DEATH 1 Georgia Barter was in a long-term abusive relationship and during that time came to the attention of a number of police forces across southern England where there were allegations of domestic abuse. Following an assault by her partner on the 5th April 2020 she undertook an act of self- harm which resulted in her death on the 26th April 2020. 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. – Georgia was a 32year old female who died as a result of domestic abuse and I recorded a conclusion of unlawful killing. She had come into contact with a number of police forces in southern England over the course of an abusive relationship. The concern I have is that there is difficulty for front line officers in police forces across the country to easily access the police national database to check on individuals who are suspected of domestic abuse. They are unable to easily identify if the individual has a history of reported domestic abuse in areas outside that forces’ borders. This would allow police to be more proactive in their dealings with victims of domestic violence. I understand that some forces have implemented changes to facilitate better exchange of information and access to PND. However, I am concerned that there may be forces which continue to have limited access for front line police officers to the PND. This is on a background of rising numbers of domestic violence cases in this country. It accounts for 20% of all crime in Essex. I have been informed there is a plan to undertake a technological overhaul in the Home Office and I would consider this matter something that should be brought to your attention to prevent future deaths. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] 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 27th 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 the family of Georgia Barter. I have also sent it to the local Director of Public Health who may find it useful or of interest. Commissioner of the Metropolis, 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. 2 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 [DATE] 2nd October 2025 [SIGNED BY CORONER] 3
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.
Minister of State for Policing and Crime 2 Marsham Street London SW1P 4DF www.gov.uk/home-office 7 November 2025 Dr Shirley Radcliffe Assistant Coroner 124 Queens Road Walthamstow E17 8QP Dear Dr Radcliffe, Thank you for your correspondence of 2 October 2025 to the Home Secretary enclosing a copy of the Regulation 28 Report to Prevent Future Deaths, following the inquest into the death of Georgia Jay Barter. I am replying as the Minister of State for Crime and Policing. I would first like to express my deepest condolences to Georgia’s family for their loss. The Police National Database (PND) is a national intelligence sharing system, which provides a consolidated view of data held locally by police forces and Law Enforcement Agencies. The PND contains 6.3 billion searchable records and 19m images. It uses algorithms to match people of interest, locations, vehicles, events and other items. Around 1.3m PND searches are completed each month. PND is used by 43 police forces in England and Wales, Police Scotland, Police Service of Northern Ireland, Isle of Man Police and the States of Jersey Police. Data from PND is provided to frontline officers by designated and specially trained staff in each police force. These account for c. 12,000 licences. The Home Office and National Police Chiefs’ Council (NPCC) work and pro-actively engage with police forces to ensure that their allocation of licences is managed effectively and provides PND access to key areas of operational policing. The PND went live in 2011 and receives regular technical upgrades. The Home Office has a current programme designed to alleviate some of the current legacy challenges and to stabilise this Critical National Infrastructure application prior to any wider transformation of police intelligence. The PND has a system of intensive monitoring and service support, and consistently meets its service level agreements for End-user Availability. Tackling violence against women and girls, including domestic abuse, is a top priority for this Government with a manifesto mission to halve violence against women and girls in a decade. We will deliver a cross-government transformative approach, underpinned by a new strategy which we aim to publish as soon as possible. In February 2025, we announced a new National Policing Centre for VAWG and Public Protection. We are investing £13.1 million this financial year (2025/26) with the new Centre launched in April 2025. This funding includes an uplift of nearly £2 million to enable policing to better target these crimes. I hope you find this response helpful. Very best wishes, Minister of State for Policing and Crime
See every Prevention of Future Deaths report matching Community health care and emergency services related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.