Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0531, written 22 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 | 22 Oct 2025 |
|---|---|
| Reference | 2025-0531 |
| Deceased | Amy Cross |
| Coroner | Peter Harrowing |
| Coroner area | Avon |
| Category | Alcohol, drug and medication related deaths · 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Mother of the Deceased
1. NHS England
2.
3. Practice Plus Group
4. Mitie Care and Custody
5.
IPRS Aeromed
6. Chief Coroner
1
CORONER
I am Dr. Peter Harrowing, LLM, Area Coroner, for the coroner Area of Avon
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 4th July 2023 I commenced an investigation into the death of Ms. Amy Jo Cross
age 31 years. The investigation concluded at the end of the inquest on 3rd October
2025. The conclusion of the jury was was that the medical cause of death was I(a)
Consequences of chronic alcohol misuse with sudden cessation of alcohol
consumption. The conclusion of the jury as to the death was natural causes.
1
4
CIRCUMSTANCES OF THE DEATH
On 9th June 2023 Ms. Cross was arrested by police officers in Torquay and taken to
Torquay Police Station where she was detained. She reported withdrawal symptoms
due to drugs and/or alcohol and was seen at the police station by a registered nurse
from Mitie Care & Custody. No medication was administered at that time. That same
day Ms. Cross was transferred to Exeter Custody Suite where she was seen the
following morning, the 10th June 2023, by a paramedic from Mitie Care & Custody.
There were concerns that she was still experiencing withdrawal symptoms and Ms.
Cross was administered dihydrocodeine and diazepam for opiate and alcohol
withdrawal respectively.
A short while later she was then taken to Exeter Magistrates Court for a court
appearance. Whilst in the court cells she reported feeling unwell with nausea and
gastrointestinal symptoms and was seen by a registered nurse from IPRS Aeromed.
Ms Cross was administered cyclizine tablets for her nausea and omeprazole tablets
for her gastrointestinal symptoms.
Following the court appearance Ms. Cross was remanded in to custody and
transported to HMP Eastwood Park where she arrived at around 15:45 hours on 10th
June 2023. Ms. Cross reported that she was feeling nauseous and had vomited on
the journey to the prison. As part of the reception process at the prison she was seen
by a paramedic from Practice Plus Group who was concerned that Ms. Cross had
withdrawal symptoms. A video consultation then took place a short while later at
around 16:52 hours with a GP also from Practice Plus Group who prescribed
methadone and diazepam for opiate and alcohol withdrawal symptoms respectively.
At 18:43 hours, before any medication was administered to Ms. Cross, she was found
unresponsive in her cell. A Code Blue was sounded and paramedics attended.
Despite all efforts she could not be resuscitated and she was pronounced dead at
19:47 hours.
During the course of my investigation I became aware that the only information
relating to Ms. Cross which was passed from the police, to the prisoner escort service
operated by Serco, to the court, and to the prison was the digital Person Escort
Record (PER). This document completed initially by a police officer in Torquay did not
have up to date details of any medical interventions and no further details were added
later. When Ms. Cross arrived at the prison it was not known to healthcare
professionals at the prison as to what medication had been administered either at a
police station or at the court. There was no system in place to transfer healthcare
related information or any clinical records between the various organisations involved
in Ms. Cross’ care on the 9th and 10th June 2023.
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. –
(1) There is no system to ensure that important healthcare information including
recent administration of medicines and the results of physical observations is
passed between separate providers of healthcare in the criminal justice system at
the time a person is conveyed between the police, the court and the prison.
(2) There is no standard medical records system which can be accessed by each
healthcare organisation to ensure the efficient and effective transfer of medical
information.
2
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisation has 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 16th December 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
Plus Group. Mitie Care and Custody, IPRS Aeromed, and the Chief Coroner.
mother of the deceased, Practice
I shall send a copy of your response to
and the above organisations.
I have sent a copy of my report to the Chief Coroner.
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. She may send a copy of this report to any person who she 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
20th October 2025
Area 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.
Dr Peter Harrowing LLM
Area Coroner – Area of Avon
Old Weston Road
Bristol
BS48 1UL
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
26/11/2025
Dear Dr Harrowing
Re: Regulation 28 Report to Prevent Future Deaths – Amy Jo Cross who died on
10 June 2023 at HMP Eastwood Park whilst on remand
Thank you for your Report to Prevent Future Deaths (hereafter ‘Report’) dated 20
October 2025 concerning the death of Amy Jo Cross on 10 June 2023. In advance of
responding to the specific concerns raised in your Report, I would like to express my
deep condolences to Amy’s family and loved ones. NHS England is keen to assure
the family, and the Coroner, that concerns raised about Amy’s care have been listened
to and reflected upon.
Your Report raises the concerns outlined below, which I will endeavour to provide a
response to:
1) There is no system to ensure that important healthcare information including
recent administration of medicines and the results of physical observations is
passed between separate providers of healthcare in the criminal justice system
at the time a person is conveyed between the police, the court and the prison.
(2) There is no standard medical records system which can be accessed by each
healthcare organisation to ensure the efficient and effective transfer of medical
information.
The Digital Person Escort Record (DPER) is a system in place designed to share
information regarding an individual’s journey along the criminal justice system
pathway. The DPER system is owned by the Ministry of Justice. The DPER makes
provision for information to be shared from police custody onwards to the Prison Escort
and Custody Services (PECS) provider, through to PECS services operating within
court custody settings and then for transmission to a prison or Youth Offenders
Institute (YOI).
NHS England is not responsible for commissioning police custody healthcare services;
this function sits with Police & Crime Commissioners. The Police & Crime
Commissioner for Devon & Cornwall Constabulary is responsible for commissioning
police custody healthcare services at the Torquay and Exeter police stations. The
police are responsible for detailing relevant health information on the individual’s
DPER within police custody suite settings, usually having taken advice from the police
custody healthcare provider.
NHS England does commission Liaison & Diversion services, which also operate with
police custody suites, addressing mental health and wider vulnerabilities. There is no
indication that a referral was made in this case to Liaison & Diversion services at either
Torquay or Exeter police custody suites. Liaison & Diversion services do not currently
have access to enter information directly onto the DPER, but with an individual’s
consent, they will share relevant health information with the police and the police will
be responsible for updating the DPER. NHS England is in discussion with PECS to
commence pilot schemes in London and West Yorkshire, whereby PECS will issue
licences to Liaison & Diversion Services, to enable them to directly access the DPER
and enter health information. The pilots are expected to commence in 2026 at the
following sites:
• London – Charing Cross Police Station and Westminster Magistrates’ Court
• West Yorkshire – Kirklees, Leeds and Wakefield Police Stations and Leeds
Magistrates’ Court
The start date is anticipated to be around February / March 2026, as stringent
monitoring of licences issued to the L&D service providers (thereby avoiding the need
to access Policy and Probation systems) will need to take place as a prerequisite to
access the DPER, and the pilots are anticipated to take place over the 12 month period
following this.
The findings, information and any learning from this case will be tabled at a future NHS
England Health and Justice Delivery Oversight Group (HJDOG). The HJDOG is the
senior leadership forum, which holds responsibility for the oversight of delivery and
continuous improvement in Health and Justice commissioned services, through both
national and regional teams. All health and justice related Reports to Prevent Future
Deaths are shared and discussed at the HJDOG, and assurance is sought from
regions where learning and action is identified.
NHS England’s national health and justice team has also engaged with colleagues
from the South West region on the concerns raised in your report.
I would also like to provide assurance about the national NHS England work taking
place around the Reports to Prevent Future Deaths. All reports received are discussed
by the Regulation 28 Working Group, comprising Regional Medical Directors and other
clinical and quality colleagues from across the regions. This ensures that key learning
and insight around events, such as the sad death of Amy, are shared across the NHS
at both a national and regional level. This helps NHS England pay close attention to
any emerging trends that may require further review and action.
I would like to thank you for bringing these important issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely
National Medical Director
NHS England
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