Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0527, written 20 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 | 20 Oct 2025 |
|---|---|
| Reference | 2025-0527 |
| Deceased | Stuart Fowkes |
| Coroner | Joanne Lees |
| Coroner area | The Black Country |
| 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Chief Constable Devon & Cornwall Police 1 CORONER I am Mrs Joanne Lees Area Coroner for the coroner area of The Black Country. 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. https://www.legislation.gov.uk/ukpga/2009/25/schedule/5 https://www.legislation.gov.uk/uksi/2013/1629/part/7 3 INVESTIGATION and INQUEST On 27/5/25 I commenced an investigation into the death of STUART MARTIN FOWKES aged 35 years who died on 26/05/2025. The investigation concluded at the end of the inquest on 30/9/2025. The conclusion of the inquest was SUICIDE. 4 CIRCUMSTANCES OF THE DEATH was suicidal. He was also likely under the influence of STUART MARTIN FOWKES resided in the Black Country at 195 Foxdale Drive Brierley Hill. On the late evening of 25/5/25 he travelled to his Mothers address in Cornwall after an incident involving his ex-partner. Whilst at his Mothers address, he reported to her that he alcohol. After approximately 2 hours, he left the address and travelled out of Devon & Cornwall Police Area and travelled back to the West Midlands and was picked up on ANPR cameras heading towards Birmingham at 08:09 on 26/5/25. He was placed as wanted on PNC at 08:25. He was later confirmed as being in Birmingham by his Mother at approximately 13:00 pm. WMP attended Mr Fowke’s home address later that evening in response to a concern for safety reported by Mr Fowkes’s ex-partner. Mr Fowkes vehicle was parked outside of the address. Police Officers have knocked the door, enquiries have been made at local hospitals, police custody in addition to neighbours spoken to, multiple calls and messages sent. A decision was been made to force entry to the address, Mr Fowkes was located with a ligature . DCP had a recorded log entry ref made to DCP by Mr Fowkes’s Mother on 26/5/25 timed at 00:52. of a domestic and suicidal report 5 CORONER’S CONCERNS 1 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) DCP had a recorded log entry ref of a domestic and suicidal report made to DCP by Mr Fowkes’s Mother on 26/5/25 timed at 00:52. Coronial enquiries elicited a response from a PC the details of that report being from lives in Devon and Cornwall area. She reported her adult son Stuart Fowkes, born 17/6/89 had left her property in a vehicle whilst in drink and suicidal. Prior to leaving, Fowkes had been shouting and swearing at his mum who confirmed (Mother of the deceased) who and whilst close to her, threatened to put his fist in her face. She said she couldn’t stop him leaving as she thought he was going to hurt her. He had told her that if he hadn’t come down to see her tonight, he would have gone to B and Q and harm himself. (2) DCP recorded a second reference to Mr Fowkes being suicidal under the same reference that Mr Fowkes is suicidal and that his father committed suicide 8 years ago in Birmingham. at 00:56 and 01:17 including further information (3) DCP had recorded a known risk to Mr Fowke’s life. (4) DCP appear to have been aware of Mr Fowke’s risk of suicide in the early hours of 26 May 2025. (5) WMP conducted an internal investigation which revealed that no risk to Mr Fowke’s life was shared with West Midlands Police by Devon and Cornwall Police. WMP reported that based on information from DCP, Mr Fowkes was wanted for drink driving and domestic abuse offences. By the time Mr Fowke’s ex-partner raised a concern for his safety and made reference to suicide it is likely Mr Fowkes was already deceased. 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 19/12/25. 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 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. 2 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 20/10/25 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.
Devon & Cornwall POLICE Assistant Chief Constable Police Headquarters, Middlemoor, Exeter, Devon, EX2 7HQ 0 101 Non-urgent © 9 9 9 in an emergency O@DC_Police @dc_police.999 0 www.devon-cornwall.police.uk © DCPolice O DevonAndCornwallPolice FAO: Area Coroner For the Black Country Mrs Joanne Lees Jack Judge House Halesowen Street Oldbury West Midlands B69 1AJ Date: 12 December 2025 Dear Mrs Lees Joint Legal Services Devon & Cornwall Police Middlemoor, Exeter Devon EX2 7HQ Prevention of Future Deaths: Stuart Martin Fowkes I am in receipt of the Regulation 28 Report to Prevent Future Deaths dated 20 October 2025 addressed to the Chief Constable of Devon & Cornwall Police. I offer my sincere condolences to the family and loved ones of Mr Fowkes following the outcome of this inquest. I am Assistant Chief Constable raised on behalf of the Chief Constable under Regulation 29 of the Coroners (Investigations) Regulations 2013. , and I am authorised to respond to the points I have been assisted in the completion of this Response by Detective Superintendent J and Superintendent The information and concerns raised within the Regulation 28 Report has been considered in detail. Those concerns are understood to be as follows: NOTE: With effect from 1 January 2019, fax communication will not be possible. Documents can either be sent via hard copy post or via email to legalservices@devonandcornwall.pnn.police.uk Joint Legal Services for Devon & Cornwall Police and Dorset Police gather and hold personal data. This may be shared where necessary with third parties acting for and on behalf of the Chief Constable. Personal data is processed securely at all times and is held no longer than is necessary. The retention period is six years in accordance with the Limitation Act 1980. Retention can be longer on a case by case basis where this is necessary and in accordance with the Management of Police Information (MoPI). If you wish to know more about how we process personal data please do visit our respective websites at: http://www.dorset.police.uk/default.aspx?page=3882 https://www.devon-cornwall.pollce.uk/your-right-to-lnformation/data-protectlon-requests/privacy-notlcefair-processing/ www.devon-cornwall.police.uk www.dorset.police.uk (1) DCP had a recorded log entry ref 20250526-0051 of a domestic and suicidal report made to DCP by Mr Fowkes’s Mother on 26/5/25 timed at 00:52. Coronial enquiries elicited a response from a PC details of that report being from in Devon and Cornwall area. She reported her adult son Stuart Fowkes, born 17/6/89 had left her property in a vehicle whilst in drink and suicidal. Prior to leaving, Fowkes had been shouting and swearing at his mum and whilst close to her, threatened to put his fist in her face. She said she couldn’t stop him leaving as she thought he was going to hurt her. He had told her that if he hadn’t come down to see her tonight, he would have gone (Mother of the deceased) who lives who confirmed the to harm himself. (2) DCP recorded a second reference to Mr Fowkes being suicidal under the same reference Mr Fowkes is suicidal and that his father committed suicide 8 years ago in Birmingham. at 00:56 and 01:17 including further information that (3) DCP had recorded a known risk to Mr Fowke’s life. (4) DCP appear to have been aware of Mr Fowke’s risk of suicide in the early hours of 26 May 2025. (5) WMP conducted an internal investigation which revealed that no risk to Mr Fowke’s life was shared with West Midlands Police by Devon and Cornwall Police. WMP reported that based on information from DCP, Mr Fowkes was wanted for drink driving and domestic abuse offences. By the time Mr Fowke’s ex-partner raised a concern for his safety and made reference to suicide it is likely Mr Fowkes was already deceased. In response to those concerns I would say as follows: A review of the case of Mr Fowkes has been undertaken by Devon & Cornwall Police through an internal investigation by the Professional Standards Department (‘PSD’) completed on 11 July 2025 and this has been reviewed by the Independent Office of Police Conduct. The conclusion of that report, and of the IOPC subsequent review, was that no officer or member of Devon & Cornwall Police staff involved in this incident had committed a criminal offence or behaved in a manner which would justify brining disciplinary proceedings. As a result of the above review, consideration has been given to the following elements of this case: 1. Ensuring that mental health of an individual who is the subject of a police report is given appropriate consideration in each case. NOTE: With effect from 1 January 2019, fax communication will not be possible. Documents can either be sent via hard copy post or via email to legalservices@devonandcornwall.pnn.police.uk Joint Legal Services for Devon & Cornwall Police and Dorset Police gather and hold personal data. This may be shared where necessary with third parties acting for and on behalf of the Chief Constable. Personal data is processed securely at all times and is held no longer than is necessary. The retention period is six years in accordance with the Limitation Act 1980. Retention can be longer on a case by case basis where this is necessary and in accordance with the Management of Police Information (MoPI). If you wish to know more about how we process personal data please do visit our respective websites at: https://www.devon-cornwall.police.uk/your-right-to-information/data-protection-requests/privacy-noticefair-processing/http://www.dorset.police.uk/default.aspx?page=3882 www.devon-cornwall.police.uk www.dorset.police.uk 2. Ensuring that information sharing is effective, providing safeguarding to the individual and potentially preventing crimes against others. 3. Accepted best practice is to notify other forces (in this case, West Midlands Police) of an individual’s return to their force area and the associated potential risks, even if those risks have reduced, whether or not recorded as a missing person. It is accepted that information regarding Mr Fowkes was not shared by Devon & Cornwall It is not suggested, I understand, that the Police with West Midlands Police in this case. lack of information sharing in this case contributed towards the tragic outcome. However, it is recognised there were recommendations made, and learning taken from this incident to ensure the high level of public service we strive for within this force are met and, where necessary, improved upon. Upon receipt of the PSD Report referred to above, the Devon & Cornwall Police Contact and Resolution Centre (‘CRC’), who are responsible for the contact centre and dispatching to incidents, have taken the following steps to address the learning raised in this matter: 1. A briefing delivered to all CRC supervisors and staff as follows: This briefing is to raise awareness of a recommendation surrounding how we share information with other forces following a coroner’s inquest to the death of a Male who sadly took his own life. In May 2025 the force received a 101 call from another force which informed us there was a potential drink driver, there were links to a domestic and he had suicidal ideology. We never located the male in force and had information he had returned to his home force. The recommendation highlights a call back to that force would have been best practice to prevent crime in that area and offer information to help safeguard the individual. (. . .) as above can all staff please consider the recommendation that a call back is to be made where needed to share information and mitigate risks. This is also best practice if we initiate the information in force and need to make another force aware of a risk in their force area. 2. In addition, a review of Force Policy has been undertaken and Policy DCP-P-051 referring to grading and deployment is also in the process of being amended, with the addition of the below new section as follows: 3. 18 Sharing information with other forces If DCP are in possession of any information and intelligence that may have a direct impact on an individual’s wellbeing located outside of Devon and Cornwall, then this information must be shared with the relevant Force to ensure steps are taken to mitigate risk and vulnerability and to safeguard those concerned. Please see the below examples. This is not an exhaustive list: NOTE: With effect from 1 January 2019, fax communication will not be possible. Documents can either be sent via hard copy post or via email to legalservices@devonandcornwall.pnn.police.uk Joint Legal Services for Devon & Cornwall Police and Dorset Police gather and hold personal data. This may be shared where necessary with third parties acting for and on behalf of the Chief Constable. Personal data is processed securely at all times and is held no longer than is necessary. The retention period is six years in accordance with the Limitation Act 1980. Retention can be longer on a case by case basis where this is necessary and in accordance with the Management of Police Information (MoPI). If you wish to know more about how we process personal data please do visit our respective websites at: https://www.devon-cornwall.pollce.uk/your-right-to-information/data-protection-requests/prlvacy-notlcefalr-processing/http://www.dorset.police.uk/default.aspx?page=3882 www.devon-cornwall.police.uk www.dorset.police.uk (cid:127) Any call from another Force to notify that a person is coming Devon and Cornwall with vulnerabilities. DCP must notify the relevant Force If the individual subsequently leaves. (cid:127) Any individual travelling out of Devon and Cornwall where there is a concern for welfare or other vulnerabilities (DA, missing persons etc). (cid:127) Any information gained from other sources such as ANPR activations or third-party information that would be relevant to another Force. I trust the information contained within this Response provides reassurance to HM Coroner If I can assist further, please do not hesitate to contact me. Yours sincerely Assistant Chief Constable - Crime, Justice and Vulnerability Devon and Cornwall Police NOTE: With effect from 1 January 2019, fax communication will not be possible. Documents can either be sent via hard copy post or via email to legalservices@devonandcornwall.pnn.police.uk Joint Legal Services for Devon & Cornwall Police and Dorset Police gather and hold personal data. This may be shared where necessary with third parties acting for and on behalf of the Chief Constable. Personal data is processed securely at all times and is held no longer than is necessary. The retention period is six years in accordance with the Limitation Act 1980. Retention can be longer on a case by case basis where this is necessary and in accordance with the Management of Police Information (MoPI). If you wish to know more about how we process personal data please do visit our respective websites at: https://www.devon-cornwall.police.uk/your-right-to-information/data-protection-requests/privacy-noticefair-processing/ http://www.dorset.police.uk/default.aspx?page=3882 www.devon-cornwall.police.uk www.dorset.police.uk
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