Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0548, written 19 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 | 19 Oct 2025 |
|---|---|
| Reference | 2025-0548 |
| Deceased | Alexander McCormack |
| Coroner | Sophie Lomas |
| Coroner area | Northamptonshire |
| 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 The Chief Constable, Northamptonshire Police 1 CORONER I am Sophie LOMAS, Assistant 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 and INQUEST On 06 March 2023 I commenced an investigation into the death of Alexander Philip MCCORMACK aged 34. The investigation concluded at the end of the inquest on 24 September 2025. The conclusion of the inquest was Suicide. 4 CIRCUMSTANCES OF THE DEATH Alexander (Alex) McCormack was found deceased on 27th February 2023 inside a tent within Fermyn Woods Country Park, Brigstock. examination found that he had died due to A post-mortem Toxicity. In the months leading up to his death Alex had encountered a stressful situation in his ideation. He had personal expressed his suicidal thoughts and plans on many occasions and had received support services. from life which had led to mental health concerns and suicidal mental health Alex lived in Derbyshire. On 26th February 2023 Alex contacted local mental health services expressing an intent to end his life on that day. He explained the method he would use but would not disclose his location. Derbyshire police were contacted and began a high risk missing persons enquiry. As part of that enquiry cell site data was obtained which indicated that Alex's location could be within the Northamptonshire area. Northamptonshire police were asked to carry out checks on addresses linked to Alex within that area. At 1.19am on 27th February 2023 Derbyshire police formally requested that the missing persons enquiry be transferred to Northamptonshire police and that the investigation. This was accepted via email with a signed form sent. Derbyshire police emailed the transfer document so that it could be uploaded onto the Northamptonshire COMPACT system. The transfer document contains all enquiries undertaken by the transferring force, including risk assessments, known contacts / addresses and cell site data. The officer responsible for importing the transfer information was unfamiliar with the process. Another officer of the same rank was also unfamiliar with the process, whilst a third officer was able to provide some practical advice and an aide memoir but did not complete the process. Due to the difficulties in transferring the information, there was no COMPACT record on the Northamptonshire system up to the point where Alex was found deceased. Although the transfer of information did not take place, Northamptonshire police they accept primacy for Regulation 28 – After Inquest Document Template Updated 30/07/2021 did continue to undertake searches for Alex overnight but due to the vast geographical nature idenitfied by the cell site data he could not be located. Alex was found by members 2023. of public walking the morning of 27th February dogs their the on 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) The court heard evidence that when transferring missing persons cases between forces, the transfer is accepted by completion of a signed transfer document. Assuming primacy of an investigation does not depend on the importing of a COMPACT file. However, the court also heard that that until a transfer of information is complete, the receiving force may not be able to accurately assess the risk and fully take ownership of the investigation. This gives inquiry. rise to a concern that this could lead to delay in formulating lines of The court heard evidence that whilst new recruits to the force, and those promoted internally, are trained on COMPACT and importing cases, this is not covered on the induction training for transferees from other forces at a particular rank. Guidance on how to transfer / import cases is available on the force intranet but this would need to be accessed and followed by the relevant officer at the time of importing the information; esentially leaning through experience. This gives rise to a concern as it could be during a busy night shift where a Reactive Inspector has competing high risk priorities. 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 13, 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 The family of Alexander MCCORMACK Derbyshire Police 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. 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 Regulation 28 – After Inquest Document Template Updated 30/07/2021 release or the publication of your response by the Chief Coroner. 9 Dated: 19/10/2025 Sophie LOMAS Assistant Coroner for Northamptonshire 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.
Northamptonshire Police FHQ Wootton Hall Park Northampton NN4 0JQ 12th December 2025 Our Ref: Regulation 28 Report Assistant Coroner Sophie Lomas The Guildhall St Giles’ Square Northampton NN1 1DE Dear Assistant Coroner Lomas, Thank you for your Regulation 28 report dated 19th October 2025 following the inquest into the tragic death of Alexander McCormack. I appreciate the time and care taken to raise these important concerns and I want to assure you that they have been considered with the utmost seriousness. I hope the following response provides clarity and reassurance regarding the processes in place within Northamptonshire Police and the steps we are taking to strengthen them further. The process that Northamptonshire Police follow, is that within the College of Policing Authorised Professional Practice for Policing (APP). The National Police Chiefs’ Council (NPCC) shared a specific document relating to the transferring of missing persons which I have attached a full copy but will refer to the pertinent points that I deem relevant to the regulation 28 report. Ownership of the investigation The guiding principle is always to ensure that the force best placed to locate the missing person takes responsibility. This approach reduces delays and unnecessary bureaucracy, and most importantly, it provides families with direct contact with the officers actively working on their case. We recognise that any delay can cause distress, and we are committed to minimising this wherever possible. The guidance says, “When deciding where ownership of the investigation lies, the principal issue is to consider where the majority of the enquiries are and who has the greatest opportunity of locating the missing person. It is more efficient for the investigation if the police force where the majority of enquiries are being conducted takes responsibility for managing the investigation and tasking enquiries. Sending multiple requests for another force to conduct enquiries and requiring regular updates can result in unnecessary bureaucracy and delays. It is also better for the family and friends of the missing person if they can liaise with the officers who are conducting the enquiries, rather than dealing with intermediaries. However, different opinions over who should own the investigation can arise in practice. Email exchanges can be slow and ineffective, and it can prove challenging to identify the correct contact number for the relevant operational supervisor in the other force. Some officers have reported resorting to ringing 101 and waiting a considerable time to be put through to the relevant person in the other force. This is not an acceptable level of service.” Making a Request to Transfer the Investigation The process involves both the National Requesting Enquiries/Transfer Form and direct communication between operational supervisors. This dual approach ensures transparency, accountability and timely decision making. Our Duty Response Inspectors actively engage in these conversations to avoid unnecessary delays and to prioritise the safety and wellbeing of those involved. The guidance says “The requesting force seeking to transfer a missing person investigation to another force should send the National Requesting Enquiries/ Transfer Form via email to the Control Room of the receiving force or direct to the relevant operational supervisor in the receiving force who will consider the request (if that is known). The use of the National Requesting Enquiries/ Transfer Form is to professionalise the process and record the rationale for any decisions made in respect of transfers. The requesting force seeking the transfer should also contact, via telephone or video call, the relevant operational supervisor in the receiving force who is considering the request, to discuss the transfer. Whether the form is sent first, or the discussion with the operational supervisor in the receiving force takes place first, will depend on the circumstances of the case. However, both aspects of the transfer request are equally important, and both should take place.” In Northamptonshire Police, our Duty Response Cadre Inspectors will have phone calls and discussions with other forces looking to transfer a missing person. There is then a reliance on the National Transfer Form (NTF) being sent to corroborate the information indicating that the missing person is most likely in the Northamptonshire area. In keeping with this guidance, the position within Northamptonshire Police is that the form should be sent so that the operational supervisor in the receiving force who is considering the request has all the relevant details to assess the transfer and to provide an audit trail. Following this, the conversation between the requesting officer and the operational supervisor in the receiving force should take place so that the risk assessment and urgency of the missing person investigation can be effectively communicated, and any differences of opinion can be discussed and promptly resolved. The guidance says “Force control rooms are the key conduit for ensuring relevant officers can promptly contact each other by telephone or video call to discuss missing person transfers. This is due to their ability to establish the current location and contact number of the relevant operational supervisors via the radio if they are not currently located in the force control room. The contact number of the relevant operational supervisor in the receiving force should be shared with the officer requesting the transfer so that they can contact the operational supervisor direct. The Force Control Room should not refuse to share contact details and should not advise the requesting officer that they will have to wait until the relevant operational supervisor in the receiving force calls them back. If the relevant operational supervisor in the receiving force is not currently available and is not likely to be available soon, a suitable deputy should be identified to consider the transfer. If necessary, a Control Room Supervisor should consider the request if no other relevant operational supervisor in the receiving force is available.” Decisions should be made within two hours Decisions regarding transfers should be made within two hours and as soon as possible in high-risk cases. We fully acknowledge that missing person investigations can escalate quickly and may involve serious harm. Our commitment is to act decisively and collaboratively to prevent tragic outcomes. The guidance says “In all cases, irrespective of the risk assessment, decisions around transfers should be made within two hours. In high-risk cases, decisions around transfers should be made sooner if possible. The two-hour period begins at the point when the requesting force has both sent the transfer form and contacted the Control Room of the receiving force requesting contact details of the relevant operational supervisor in the receiving force. Missing person investigations can be the first stages of a serious crime and/ or result in fatal outcomes. It is in everyone’s interests that there is a proper assessment of risk and that enquiries are undertaken reflecting the level of risk. Enquiries should not be delayed because of bureaucratic obstacles. In the past, police forces have been criticised for failing to undertake enquiries quickly and, should tragic circumstances arise, the reputation of a police force could be affected if a tragic outcome could possibly have been avoided by a more rapid police response.” Transfer of Ownership We recognise the importance of equipping officers with the right knowledge and tools. While Inspectors currently hold responsibility for COMPACT transfers, we are enhancing training across all relevant ranks. Updated training packages are being developed to ensure consistency and confidence in handling these sensitive cases. This includes future transferee Inspectors and ongoing refresher sessions for existing staff. The guidance says “When the receiving force has agreed to accept responsibility for an investigation, the requesting force should promptly forward all other relevant documents and information concerning the investigation, including a copy of the initial reporting form and a summary of the enquiries conducted so far. The requesting force retains ownership of the investigation until the receiving force has confirmed receipt of relevant documents and information, and there has been a verbal handover of the investigation. The requesting force should not close their investigation without clear confirmation that all documents and information have been transferred and received, and the receiving force has formally taken ownership of the case. The requesting force should record the details of the person who agreed to take ownership of the case and details of the person who confirmed receipt of the relevant information and documents. The requesting force should also ensure that they have contacted the reporting person/ family to ensure that they are made aware of the transfer and that they are provided with the reference number and contact details of the receiving force. The receiving force should check the information and documents received and then review the risk assessment and the urgency of outstanding enquiries. In complicated, high-risk, or sensitive cases, there should be a professional briefing via telephone, video call, or in person, between SIO’s if appointed, or the investigating officers, to ensure all vital details of the investigation are communicated.” This is the practice that is followed by Northamptonshire Police which has been confirmed by our Missing Persons Investigation Unit Office Manager who also acts as our COMPACT SPOC (COMPACT is the Missing Persons system used by Northamptonshire Police), I am informed that all the pertinent information in relation to the missing person investigation should be on the National Transfer Form and it is based on that information that the Inspector agrees to accept the missing investigation. Once the National Transfer Form has been accepted and signed by the Inspector, that is when the missing case becomes the responsibility of the accepting force. It is no different to accepting a missing person from a member of the public, as soon as we accept it, the investigation becomes our responsibility. We can commence actions based on information on the National Transfer Form. If insufficient information is available there may be a delay in accepting primacy until all relevant information is forwarded, to allow the receiving force to accurately assess the risk and take ownership of the investigation. This would not be a regular occurrence as generally all relevant information would be provided upon first submission of the NTF. With regards to your concern relating to the training of officers, the below points may assist: In 2023 it was only Inspectors, MPIU Officers, the Detective Sergeant and COMPACT SPOC who could import and export missing records on COMPACT. The Current position within Northamptonshire Police is Constables and Sergeants do not have the authority to import or export a missing person on COMPACT. This is an Inspector role. Sergeants were briefly given access due to the workload of Inspectors however there were mistakes and poor decision making resulting in this authority being rescinded. All new Police Officers are given a three-hour training input on COMPACT, however transferring missing investigations would only be briefly covered due to the of PC rank not being allowed to import/export missing people. There is current guidance on importing and exporting COMPACT records on the Force Intranet, which audits show is regularly downloaded and viewed. Ensuring that Officers are appropriately trained and informed is of great importance to us as a force, new training presentations are in the process of being created for all ranks. This includes existing Cadre Inspectors, FCR Inspectors and Detective Inspectors. Additionally, there will be an updated training packing for transferring Inspectors regardless of their role. The Detective Superintendent for Protecting Vulnerable People will ensure that our Learning and Development team provide COMPACT transfer training to all future transferee Inspectors. From my review, this appears to be an isolated incident rather than a systemic issue. Nevertheless, we remain committed to learning from every case and improving wherever possible. Please be assured that we take these matters seriously and are committed to safeguarding vulnerable individuals. Thank you again for raising these concerns. Should you require any further clarification or wish to discuss this in more detail, I would be happy to arrange this. Yours sincerely, Chief Constable Ivan Balhatchet
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