Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0565, written 6 Nov 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Nov 2025 |
|---|---|
| Reference | 2025-0565 |
| Deceased | Aaron Taylor |
| Coroner | Christopher Long |
| Coroner area | Lancashire and Blackburn with Darwen |
| 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) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. , Medical Director, Practice Plus Group 1 CORONER I am Christopher Long senior coroner, for the coroner area of Lancashire and Blackburn with Darwen 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 7 September 2023 I commenced an investigation into the death of Aaron Lee Taylor, 32 years old. The investigation concluded at the end of the inquest on 29 October 2025. The conclusion of the inquest was: With the evidence provided by the pathologist, CCTV footage from 27 August and the 28 August, combined with witness statements from the prison officer who found Mr Aaron Lee Taylor at 08:05am on the 28 August 2023, Mr Aaron Lee Taylor died between 7.30pm on the 27 August 2023 and 6am on the 28 August 2023, in a cell on the premises of HMP Garth, 1 Moss Lane, Ulnes Walton, Leyland. . Taking into account the three letters that Mr Taylor wrote, the preplanning and method in which Mr Taylor died, leads us to conclude Mr Taylor did take steps intending to take his own life. There were multiple failures in the measures taken to prevent self-harm and suicide. From the evidence that has been presented in court, multiple opportunities were missed by multiple professionals (nurse, GP, prison officers, mental health nurse, Prison Offender Manager, Governor, Senior prison officer) to support or offer suitable/appropriate care and resources for Mr Taylor. Inadequate preventative steps and assessments, lack of documentation, inability to adhere to policies and procedures and a 'lack of professional curiosity' as stated by an Operations Manager from GMMH who undertook an external investigation. All contributed to Mr Taylor's death. Witness testimony from a prison officer demonstrated that the relevant observations had not been carried out on the 28 August 2023. With the evidence and testimony of the pathologist, and the uncertainty surrounding time of death, we cannot say that these observations or lack of, contributed to Mr Taylor's death. As highlighted by the external investigation carried out by GMMH, there were multiple serious failures to provide minimal/adequate mental health interventions for Mr Taylor. These serious failures and inadequacies possibly contributed to Mr Taylor's death.. 1 4 CIRCUMSTANCES OF THE DEATH Mr Taylor was discovered in his cell on 28 August 2023 by a prison officer. He was found suspended from a ligature. 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 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. – Evidence was heard that PPG Healthcare who are now responsible for healthcare at HMP Garth have not had any psychologist resource for prisoners at HMP Garth unless they have been victims of sexual assault. Even then, evidence was heard about waiting lists of many months. Evidence was also heard that a decision had not been taken to fill psychologist resource gaps by locum cover, despite those gaps having existed for 6 months 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 Friday 2 January 2026. 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: Mr Taylor's family and , Governor HMP Garth 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 Date 6 November 2025 Christopher Long 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.
Practice Plus Group
Building 1330
Arlington Business Park
Theale
Reading
RG7 4SA
HM Senior Coroner Christopher Long
Lancashire and Blackburn with Darwen
By email
16 January 2026
Dear Sir
Regulation 28: Prevention of Future Deaths report, Aaron Taylor
Thank you for your Regulation 28 Prevention of Future Deaths Report issued to Practice Plus
Group following the inquest into the death of Aaron Taylor, Deceased. Practice Plus Group would
like to express its condolences to Mr Taylor’s family and friends.
Practice Plus Group has been the main provider of healthcare services at HMP Garth since 1 April
2025.
This response addresses the matters of concern in so far as they relate to Practice Plus Group.
Matter of Concern:
Evidence was heard that PPG Healthcare who are now responsible for healthcare at HMP Garth
have not had any psychologist resource for prisoners at HMP Garth unless they have been victims
of sexual assault. Even then, evidence was heard about waiting lists of many months. Evidence
was also heard that a decision had not been taken to fill psychologist resource gaps by locum
cover, despite those gaps having existed for 6 months
Response:
The current model of psychology provision at HMP Garth consists of a 1 part-time Principal
Psychologist, 1 full-time Clinical Assistant Psychologist and 2 full time Assistant Psychologists. All
of these posts are new roles following TUPE of services and all posts are out to advert.
The Consultant Clinical Psychologist has contacted agencies to backfill the Principal Psychologist
role in the interim. Unfortunately, no suitable locum psychologist has been available to be
provided by the agency, due to a lack of psychologists in the employment market.
We currently have two candidates that have applied for the Principal Psychologist post and the
Consultant Clinical Psychologist arranged telephone calls with both candidates on the 30th
December 2025. Following this, the candidates have been offered interviews, which are due to
take place on 21 January 2026.
No applicants have applied for the Clinical Assistant Psychologist post as yet. We have made the
decision to keep the vacancy open for another month, in the hope we will receive some
1009801953.1
applications. In the event no candidates have applied for this post, a meeting will be held to
discuss consideration of a restructure of this role. We have informed NHSE Commissioners of the
possible restructure.
The Assistant Psychologist post is also out to advert. In the event candidates are appointed for
this post before we have a Principal Psychologist in post, clinical supervision will be provided by a
psychologist from another site within PPG.
Patients requiring routine psychology interventions who are not case loaded to a mental health
nurse are provided with support from a Health and Wellbeing Practitioner and Nurse Associate,
this provides ongoing support and safety-netting to patients, including monitoring and escalation to
the Mental Health nursing team if required. Upon escalation they can then be case-managed by a
Mental Health nurse. No further patients are being added to the waiting list while we await
appointment of the psychologists. Anyone who is now referred for psychological services is
allocated a health and well-being practitioner, who can undertake a lot of low level work that can
be done in meantime, in preparation for psychological input.
Patients requiring urgent psychological interventions are discussed at a multi professional
complex case conference (MPCCC) at a local level and referred to the Regional MPCCC for
review and care planning. Provision is in place to ensure urgent patients are provided with
psychological support from the region’s established psychology workforce.
HMP Garth is also having discussions with the neighbouring prison, HMP Wymott, as to whether
we could share their psychological resources while we await the posts being filled.
We are committed to providing a high-quality healthcare service at HMP Garth and are doing
everything we can to ensure those detained there are as safe as possible and receive the best
quality care. We are deeply sorry that Aaron Taylor died while receiving care from our service and
we will ensure that the lessons learnt are not just implemented at HMP Garth but across Practice
Plus Group’s services.
We trust that the above responses provide the information that you require but please do not
hesitate to contact us if Practice Plus Group can be of any further assistance.
Yours faithfully
Medical Director
Health in Justice
Practice Plus Group
On behalf of Practice Plus Group
1009801953.1
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