Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0530, written 21 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 | 21 Oct 2025 |
|---|---|
| Reference | 2025-0530 |
| Deceased | Paul Appleby |
| Coroner | Anne Pember |
| Coroner area | Northamptonshire |
| Category | Community health care and emergency services related deaths |
| Organisation named | Northamptonshire Healthcare NHS Foundation Trust |
| 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 before an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: , Operational Team Leader, Liaison and Diversion Team, Northamptonshire Healthcare NHS Trust, Newland House, Campbell Square, Northampton 1 CORONER I am Anne PEMBER, Senior Coroner for the coroner area of Northamptonshire 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 On 25 February 2025 I commenced an investigation into the death of Paul John APPLEBY aged 62. The investigation has not yet concluded and the inquest has not been heard. 4 CIRCUMSTANCES OF THE DEATH Paul Appleby had been arrested for a drink driving offence on Friday 21st February 2025. He was charged and remanded in custody. Late on the evening of 21st February 2025, Mr Appleby was assessed by Dr seen by Court Liaison and Diversion before release from custody. (Forensic Medical Examiner) who advised that Mr Appleby should be In the early of Saturday 22nd February, the detention officer at Wheatley Wood Justice Centre, Cherry Hall Road, Kettering, sent an email to the community psychiatric nurse at the Criminal Justice Centre to inform him or her that Mr Appleby should be reviewed prior to being released. Mr Appleby was not seen by the Liaison and Diversion Team. At around lunchtime on Saturday 22nd February 2025 Mr Appleby was found deceased having jumped from the Grosvenor Centre, Northampton. 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: I understand that the Liaison and Diversion Team at Northampton has not operated a Saturday Court Service for several years. Previously an ‘On Call’ service has been provided. I am concerned that this lack of service could give rise to future deaths. 6 ACTION SHOULD BE TAKEN Regulation 28 – Before Inquest Document Template Updated 30/07/2020 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 16, 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 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 Dated: 21/10/2025 Anne PEMBER Senior Coroner for Northamptonshire Regulation 28 – Before Inquest Document Template Updated 30/07/2020
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.
Dear Mrs Pember Thank you for your e-mail responding to our letter to you concerning the regulation 28 report you issued in connection with Mr Appleby. We note that you are holding the inquest into Mr Appleby’s death next week. You asked us to comment on the statement of Detention Officer your e-mail, with reference to our letter to you. We note from exchange with one of our employees, 2025 about a request he had made for ‘APPLE’ to be reviewed prior to release. , a copy of which you shared with us in statement that he had an e-mail , in the early hours of the morning of Saturday 22 February works at the Northampton based Criminal Justice Centre for the Liaison and Diversion Team. His role is to assess people in Custody and if he were called by the Courts on a weekend to assess he would go over to Court as there is not a dedicated weekend worker (as per the Standard Operating Procedure or SOP we mentioned to you in our previous letter). The e-mail was opened by at the start of his shift. The e mail had the incorrect name and had no detail of the concerns; it also did not state that an assessment was needed prior to release (often the team assess after release from Custody). Mr Appleby left Weekly Woods Kettering prior to police ledger is updated and person removed, without full and accurate person identifiable data (PID) and not being based at Weekly Woods Custody he could not make any further enquiries. Also, as it had not used the agreed pathway (referral via the shared e-mail) and based on the content of the e-mail, there was no sense of risk or immediacy. There was no phone call from Court requesting an assessment. The practitioner based at Weekly Woods was unexpectedly off that day but would have also started the shift following PA leaving and with the limited info to proceed. starting shift, once someone leaves Custody the As stated in our letter to you, to mitigate the risk of a similar situation occurring in the future, we have reissued the SOP to those operating Saturday courts to remind them how to make referrals to our services. Please do not hesitate to contact us in advance of the inquest next week if you have any further questions for us. Kind regards , Director of Corporate Governance Northamptonshire Healthcare NHS Foundation Trust | St Mary’s Hospital | 77 London Road |KETTERING | NN15 7PW This e-mail and any files transmitted with it are confidential and intended solely for the use of the individual or entity to whom they are addressed. Any views or opinions expressed are those of the author and do not represent the views of the Trust unless explicitly stated. The information contained in this email may be subject to public disclosure under the Freedom of Information Act 2000. Unless the information is legally exempt from disclosure, the confidentiality of this email and your reply cannot be guaranteed.
See every Prevention of Future Deaths report matching Northamptonshire Healthcare NHS Foundation Trust, 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.