Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0536, 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 | 2025-0536 |
| Deceased | Steven Davidson |
| Coroner | Stephen Simblet |
| Coroner area | Essex |
| Category | Suicide (from 2015) · State Custody 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. HCRG CARE GROUP, The Heath Business & Technical Park, Runcorn, Cheshire, WA7 4QX 1 CORONER I am STEPHEN SIMBLET KC assistant coroner, for the coroner area of Essex. 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 20th March 2024, I commenced an investigation into the death of Steven Roy Davidson. The investigation concluded at the end of the inquest on 22nd October 2025. The conclusion of the inquest was a narrative conclusion, with the jury including the finding that where he created a ligature while a convicted but unsentenced prisoner in Chelmsford Prison. They also found (albeit without it being causative) that important information about the deceased and previous acts of self- harm had not been passed on. 4 CIRCUMSTANCES OF THE DEATH The deceased died while in prison. He had been in prison on a previous occasion, in 2012- 13, during which he had self- harmed on a number of occasions, including ligaturing himself to the point of unconsciousness on more than one occasion, . He had during that prison stay also been in his cell. This information was contained and documented within the System One Healthcare Records, which were available to the staff in Chelmsford Prison. However, the evidence from all of the healthcare witnesses involved, which included a number of Registered Mental Nurses carrying out a mental health review of the deceased’s care, and the Nurse conducting the initial Reception Health Screen, was that none of those people were aware of the deceased’s history. Evidence was given that such past history is clinically significant to any assessment of the risk of self harm. The evidence from some of these staff was that they had not been able to navigate the records very easily, and/or despite interrogating the records, had not found this important information. There was evidence given from senior personnel in the company involved in supplying health care to Chelmsford and other prisons that it is possible to word- search for words such as, “self harm” or “suicide”. 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) Health Care Staff at HMP Chelmsford say that they are: (i) (ii) (iii) not able to navigate the System One records sufficiently well to find information about previous incidents of self- harm in prison; and/ or not sufficiently aware of the importance of searching the records made by clinicians during previous prison stays when conducting Reception Health Screens and/ or reviews of a prisoner’s mental health needs. May not be sufficiently trained to understand and utilise System One records to find previous history, including incidents of self- harm in custody. 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 15th 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 the Chief Coroner and to the following Interested Persons : (1) (2) The Ministry of Justice; , the father of the deceased; 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 [DATE] 21st October 2025 [SIGNED BY CORONER] 2
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.
HCRG Care Group The Heath Business & Technical Park Runcorn Cheshire WA7 4QX sent via email 12th December 2025 Dear Mr Simblet I write further to your Report to Prevent Future Deaths (hereafter Report) dated 21st October 2025 concerning the death of Steven Roy Davidson on 12th March 2024 at HMP Chelmsford. I am responding to this report on behalf of HCRG Care Group in my role as Regional Director. I would like to take this opportunity to express my deep condolences to Mr Davidson’s family and loved ones. HCRG welcome the opportunity to reassure Mr Davidson’s family, other service users and yourself that the concerns raised in the Report have been listened to and reflected on, and that HCRG is taking action to ensure we learn from Mr Davidson's death and continually improve the service we provide. I adopt the numbering in your report and respond below in turn. 1. Difficulty navigating SystmOne records SystmOne is the NHS electronic patient record system used in prison and custodial healthcare settings across the country. NHS North of England Commissioning Support (NECS) provides training and technical support for users of SystmOne, including system navigation, search functions and information retrieval. HCRG has amended its training provision so that all new staff will now receive structured SystmOne training as part of their induction, provided by NECS and recorded in the mandatory training schedule. This will include guidance on locating clinical information that may be stored in different parts of the system (see further below). Refresher training will also be provided to existing staff within three months and recorded in their personal training record. All agency staff will be required to confirm in writing that they understand how to navigate clinical records held in SystmOne and this will be recorded in the ShareDrive. Any long-term agency staff will also complete the same structured training as permanent staff. HCRG Care Services Ltd, company number 7557877 registered in England and Wales at The Heath Business and Technical Park, Runcorn, Cheshire WA7 4QX Send any correspondence to the address at the top of this letter 2. Searching records made during previous prison stays All Practitioners conducting clinical assessments should, as part of good practice, review relevant patient history when undertaking reception screenings, mental health reviews or risk assessments. In this case, it appears that practitioners focused primarily on Mr Davidson's current presentation rather than reviewing earlier records in depth. HCRG will reinforce through clinical governance that risk-related history should be considered when assessing patients, and that in some cases this may involve searching beyond the default summary record view. To ensure that records are being reviewed appropriately, the existing monthly audit of clinical notes will now include specific checks as to whether practitioners have accessed relevant historic information when assessing risk. Findings from the audit will feed into governance meetings and quality and performance monitoring available to NHS England commissioners. Historic risk-related information from earlier custody periods, including 2012–13 (as was the case here), was recorded in SystmOne before the widespread adoption of structured clinical terminology such as SNOMED (Systematised Nomenclature of Medicine Clinical Terms). At that time, information was commonly entered as narrative notes, scanned correspondence or imported documents, rather than as coded events. These formats are held within the system but do not automatically appear in structured risk or summary views routinely used during reception health screens, risk assessments or mental health reviews. This has highlighted the importance of staff understanding when and how to access older or non-coded sections of the record where historic risk-related information may be stored. The adoption of SNOMED and structured clinical coding enables more recent risk-related entries to be recorded in a format that surfaces more reliably in summary and risk views. Training and governance measures will therefore be focused on ensuring that staff can interpret both coded and historic record elements when assessing risk. 3. Understanding and utilising SystmOne As described above, all staff with access to SystmOne will complete structured training provided by NECS, which will cover system navigation, use of search tools, and how to retrieve both coded and historic information from different sections of the clinical record. This training has been incorporated into induction programmes and is now included in the mandatory training schedule for existing staff. HCRG’s Performance and Quality teams are embedding SystmOne training into existing governance and supervision processes to ensure consistent and safe use of the platform. Staff may also contact the Performance and Quality Lead if further clarification is needed, either directly or via their line manager. As is usual practice, we will continue to work with the teams to understand their experiences and to continually improve our services both in response to incidents and as part of day-to-day operations. HCRG Care Services Ltd, company number 7557877 registered in England and Wales at The Heath Business and Technical Park, Runcorn, Cheshire WA7 4QX Send any correspondence to the address at the top of this letter While we are confident that this response addresses the points raised in your Report, we would welcome a further opportunity to clarify any points which you, or Mr Davidson's family, consider require it. Yours sincerel Regional Director for Specialised, Surrey and Luton HCRG Care Group HCRG Care Services Ltd, company number 7557877 registered in England and Wales at The Heath Business and Technical Park, Runcorn, Cheshire WA7 4QX Send any correspondence to the address at the top of this letter
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