Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0519, written 15 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 | 15 Oct 2025 |
|---|---|
| Reference | 2025-0519 |
| Deceased | Malik Bunton |
| Coroner | Catherine Cundy |
| Coroner area | North Yorkshire and York |
| Category | Suicide (from 2015) |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Ministry of Defence 1 CORONER I am Catherine CUNDY, Area Coroner for the coroner area of North Yorkshire and York 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 20 July 2023 I commenced an investigation into the death of Malik BUNTON aged 21. The investigation concluded at the end of the inquest on 03 October 2025. The conclusion of the inquest was that he died as a result of suicide. CIRCUMSTANCES OF THE DEATH 4 On the evening of the 17th of July 2023 Malik Bunton was found suspended from a ligature . His death was confirmed at the scene on the same date. During the inquest I heard evidence in relation to two separate incidents of self harm/suicidal ideation which preceded Mr Bunton's death. The first occurred on 26 March 2023 when Mr Bunton entered the River Ouse while intoxicated and with suicidal intent. The second occurred on 11 July 2023 when Mr Bunton consulted with a GP in the Defence Medical Service in relation to self harm secondary defence mental heath services for assessment but sadly took his own life six days later. . He was referred to 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) While I was unable to conclude that the following concerns caused or contributed to Mr Bunton’s death, I make this report as I consider they impeded the ability of the RAF to properly assess Mr Bunton’s suicide risk and, if repeated, will continue to impede the ability of the RAF to learn lessons from his death and mitigate future risk to other service personnel. 1. There was insufficient inquiry made of Mr Bunton and those service personnel most closely involved with the 26 March 2023 incident as to the circumstances in which it occurred. While it was accepted that Mr Bunton chose to minimise the incident, it could easily have been established by proper inquiry of these parties that Mr Bunton had sent a concerning message before entering the water with suicidal intent, and then been taken by the police to hospital where he was offered psychiatric assessment. The results of these OFFICIAL Regulation 28 – After Inquest Document Template Updated 30/07/2021 inquiries would have better informed subsequent oversight of Mr Bunton’s welfare by his Chain of Command. 2. There were weaknesses in the Clinical Care Review process undertaken by the Defence Medical Service following Mr Bunton’s death. While the review of the 11 July 2023 consultation occurred very promptly after Mr Bunton’s death, the GP involved in the consultation was unaware that her informal discussion of the case with a senior colleague was being captured as part of a formal review process. She was also never asked to check the accuracy of the contents of the review document produced following this discussion, which compromised the accuracy of the review document itself, as well as impacting on evidence subsequently available to the Service Inquiry and the inquest. The purpose of the Clinical Care Review process is to identify any concerns around clinical decision-making and mitigate the risk of recurrence of the same, and should therefore be based on a clear and verified record of events. There were inexplicable delays and some apparent deliberate obstructions to the 3. gathering of important evidence from key witnesses. This impacted on the extent and quality of evidence ultimately available to both the Service Inquiry and the inquest. Examples of this were – The long delays in obtaining formal accounts from key witnesses either in writing or The absence of any account from Mr Bunton’s colleague who attended hospital with - via an interview process. - him following the 26 March 2023 incident. Such an account would have informed the process of inquiry referred to at point 1 above as well as the Service Inquiry and inquest. - The decision to delete Mr Bunton’s service email account without consideration of its potential importance in the context of a suspected suicide. - some months following Mr Bunton’s death. The absence of a clear and contemporaneous account of the 11 July 2023 GP - consultation, either in the Clinical Care Review document and/or a separate formal account of events obtained from the doctor concerned. Withholding statements of two key witnesses from the Service Inquiry panel for 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 December 03, 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 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 person who I believe may find it useful or of interest. OFFICIAL Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 Dated: 15/10/2025 Catherine CUNDY Area Coroner for North Yorkshire and York OFFICIAL Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
THE LORD COAKER
MINISTER FOR THE HOUSE OF LORDS
MINISTRY OF DEFENCE
FLOOR 5 ZONE B MAIN BUILDING
WHITEHALL LONDON SW1A 2HB
27 November 2025
Dear Ms Cundy,
Thank you for your report of 15 October 2025 to the Defence Secretary following
your Inquest into the death of AS1 Malik Bunton. First and foremost, I would like to
offer my sincere condolences to AS1 Bunton’s family, friends and colleagues.
You have raised concerns regarding the welfare support provided to and oversight of
AS1 Bunton, the clinical care review process, and the recovery of evidence. I take
the health and wellbeing of our Armed Forces personnel extremely seriously and
wholly share your desire to prevent future deaths. I have considered each of your
concerns below.
The Chain of Command’s management of AS1 Bunton’s welfare.
I have sought assurance that the Chain of Command at RAF stations are equipped
and trained to respond to welfare concerns and that effective welfare training is
provided to them. I am assured that the training and processes in place enables
managers to safeguard the welfare of their personnel, and I am aware that the RAF
has reiterated the importance of ensuring it is continually developed. I will continue to
ensure that Defence does all it can to care for its personnel.
It is of course unfortunate that the full details of the River Ouse incident were not
known to the Chain of Command in the immediate aftermath of the incident. I am
assured that the Chain of Command acted properly based on the information
available to them at the time and having had no prior concerns regarding AS1
Bunton’s mental health or welfare.
The Clinical Care Review (CCR) Process
On receipt of your report, the Defence Medical Services (DMS) conducted a review
of the CCR undertaken after AS1 Bunton’s death. I can confirm that the CCR was
shared by the Senior Medical Officer with the GP. Unfortunately, due to the passage
of time, the GP was unable to recall this fact at the inquest. However, I am assured
that the correct process was followed in relation to the CCR, and that independent
scrutiny was applied to ensure early recommendations for learning were identified
and implementation plans were put in place.
Defence Primary Health Care regularly review their policies and processes, and
recent and separate work has focused on enhancing the approach to clinical reviews
of serious healthcare incidents. A key development is the introduction of an early
MINISTRY OF DEFENCE
FLOOR 5 ZONE B MAIN BUILDING
WHITEHALL LONDON SW1A 2HB
THE LORD COAKER
MINISTER FOR THE HOUSE OF LORDS
review by an experienced and independent Learning Event Review Panel, which will
supplement the individual review conducted by a local clinician. Additionally, a new
Significant Event Reporting system is being developed in partnership with the DMS
Healthcare Assurance team to improve recording of reviews and the ability to
implement lessons. This will also include a specific requirement to share CCRs with
the clinicians involved in the case. These developments build on the existing process
to ensure that the CCR process remains a robust mechanism to identify concerns
and mitigate the risk of recurrence.
Recovery of Evidence
The loss of AS1 Bunton was and remains a deeply profound tragedy for those who
knew him within the RAF. I fully recognise and appreciate the challenging and
unprecedented circumstances faced by station personnel at RAF Leeming in the
latter half of 2023 to manage wider welfare concerns and safeguard the duty of care
to those service personnel most impacted by AS1 Bunton’s death.
Nevertheless, we acknowledge the need for a more robust post incident process
within the RAF that gathers relevant material in the immediate hours and days
following an event. To address this, the Head People and Families Support, as the
RAF lead for personnel welfare, has directed that all suspected suicides within the
RAF will now be subject to an immediate fact-finding investigation. This process is
designed to ensure timely, compassionate, and thorough understanding of the
circumstances surrounding such incidents. Responsibility for gathering this evidence
and conducting an initial investigation will rest with the Station Commander and will
be formally brought into the RAF Postvention Suicide Response policy as a matter of
urgency.
Regarding the delay in providing statements to the Service Inquiry panel, I
understand that the statements in question were prepared for the inquest, and I am
assured that the delay arose from a desire to adhere to the appropriate disclosure
processes. However, further direction and guidance has been issued to ensure such
delays are avoided in the future. Furthermore, the Defence Inquests Unit is working
to implement a process to retain, where appropriate, the email accounts of deceased
service personnel. This will allow for the retrieval of relevant data, should it be
required for inquests.
Once again, my deepest condolences go out to AS1 Bunton’s family and all those
impacted by his passing. Thank you for bringing these important matters to my
attention. I hope my response has assured you that the MOD is committed to
ensuring that our processes and policies are robust, transparent and effective and
MINISTRY OF DEFENCE
FLOOR 5 ZONE B MAIN BUILDING
WHITEHALL LONDON SW1A 2HB
THE LORD COAKER
MINISTER FOR THE HOUSE OF LORDS
that we are able to truly learn lessons so we can improve the support provided to our
personnel.
Yours sincerely,
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