Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0566, 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 | 2025-0566 |
| 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. HMP Garth 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. . 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. – (1) Evidence was heard that despite several prison officers being aware of a serious incident of self-harm involving a prisoner with a history of self-harm, an Assessment, Care in Custody Teamwork process (ACCT) was not opened. No evidence was provided confirming all prison officers were ACCT trained and/or were all aware of their responsibilities in relation to ACCT (2) Evidence was also heard that keyworker sessions were not being carried out as they should have been with a prisoner who had been identified as in need of support through the keyworker scheme. A prison officer with keyworker responsibilities gave evidence that they did not know how frequently keyworker sessions should take place ( ACTION SHOULD BE TAKEN 6 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 Practice Plus Group Healthcare. 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.
Director General of Operations HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ Christopher Long Senior Coroner for the Lancashire and Blackburn with Darwen Area Coroner’s Court 2 Faraday Court Faraday Drive Preston Lancashire PR2 9NB 12 January 2026 Dear Mr Long, Thank you for your Regulation 28 report of 6 November 2025 following the inquest into the death of Aaron Taylor at HMP Garth on 28 August 2023. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as the interim Director General of Operations. I know that you will share a copy of this response with Mr Taylor’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority. You have expressed concerns regarding the level of Assessment, Care in Custody and Teamwork (ACCT) training provided to staff and the provision of keyworker sessions to prisoners in need of support. I would like to assure you that HMPPS is committed to providing prison officers with the right support, training and tools to do their jobs. All new entry officers receive a full day of training on suicide and self-harm prevention during their prison officer training. This training includes modules on the ACCT process as well as understanding and managing changes to risks, triggers and protective factors. Following completion of the prison officer training, new entry officers also have a two week local induction before becoming fully operational. In addition to the classroom training, there is an online Safety Learning Reference Library holding various guidance, templates and training material that is accessible to all staff via the HMPPS intranet. The library includes an area dedicated to ACCT which staff can access at any time. At HMP Garth a staff information notice has been issued promoting the Safety Learning Reference Library, and a Governor’s order was issued to all staff in October 2025 reiterating the process on when and how an ACCT should be opened and by whom, and on how the ACCT record should be completed. In line with HMP Garth’s current regime management plan a priority keywork model is in place, ensuring that any prisoner who has been identified as vulnerable is prioritised. A staff information notice was issued in November 2025 advising staff that a minimum of one keywork session per month is expected for all prisoners who have been identified as a priority, and this includes those who are on an ACCT. In addition to these priority sessions, staff continue to provide keywork sessions for other prisoners wherever resources allow. Keywork progress is tracked through the weekly performance meeting. I hope the measures outlined above provide you with reassurance that the matters of concern that you identified arising from the circumstances of Mr Taylor’s death have been addressed. Yours sincerely Interim Director General Operations
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