Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0591, written 18 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 | 18 Nov 2025 |
|---|---|
| Reference | 2025-0591 |
| Deceased | Steven Ruddick |
| Coroner | Crispin Oliver |
| Coroner area | County Durham and Darlington |
| Category | 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 DEATHS THIS REPORT IS BEING SENT TO: 1 1 CORONER I am Crispin OLIVER, Senior Assistant Coroner for the coroner area of County Durham and Darlington 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 19/12/2022 15:14an investigation was commenced into the death of Steven Lee RUDDICK 31/07/1984. The investigation concluded at the end of the inquest on 13/11/2025 15:15. The conclusion of the inquest was that See attached Chronology of Events and see attached sheet.. 4 CIRCUMSTANCES OF THE DEATH Mr Steven Lee Ruddick was transported by GEOAmey to University Hospital North Durham en route to HMP Durham to have his ankle checked. Whilst in the police waiting room at the hospital, Mr Ruddick and died very shortly having been to the toilet, 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) It emerged during the evidence that there is a material difference between police procedures for managing a detained person on close observations and those of GeoAmey and, it is understood, HM Prison Service in relation to using the toilet in the scenario in this case. In police custody, the detained person would be in standard cuffs and the officer would be present and observing directly during the toilet visit. In GeoAmy and Prison Service custody, in contrast, the detained person would be in a 1 metre closet chain and would be attached to the officer by means of a 1.5-2 metre chain and he/she would used the toilet without the officer observing directly. While this preserves the privacy and dignity of the detained person it can also, as in this scenario, potentially offer him/her the opportunity of removing prohibited items from the rectum without being observed and relocating them on his/her person. Further the jury did conclude that the manner in which the Level B search immediately following the toilet visit was conducted on that occasion possibly contributed to the death. Finally, by way of explanation, the evidence on the contrast in the approach of Regulation 28 – After Inquest Document Template Updated 30/07/2021 police and GeoAmey/HM Prison Service on this issue only emerged during the evidence of witnesses to the Inquest itself and it’s significance not predicted by either myself or any of the Interested Persons or their representatives before the Inquest. By that stage, MOJ had been stood down as an Interested Person (which was agreed across the board) since the Pre-Inquest Review in February 2025. Further, it was only established at the very end of the Inquest during submissions on Regulation 28 matters that the policy and procedures governing custody in the scenario here relevant is provided by PECS rather than by GeoAmey itself. Clearly, had either of these factors been different, then MOJ would have had a chance to contribute 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 January 13, 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to who may find it useful or of interest. 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 release or the publication of your response by the Chief Coroner. 9 Dated: 18/11/2025 Crispin OLIVER Senior Assistant Coroner for County Durham and Darlington 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.
Prisoner Escort and Custody Sevices HM Prison and Probation Services Unit 6, Forder Way The Office Village Cygnet Park Peterborough PE7 8GX Date: 25/1/2026 Crispin Oliver Senior Assistant Coroner for County Durham and Darlington Response to Regulation 28 Report – Preventing Future Deaths In the matter of: Steven Lee Ruddick Dear Mr Oliver, Thank you for your Regulation 28 Report dated 18 November 2025, issued following the conclusion of the inquest into the death of Mr Steven Lee Ruddick. HMPPS recognises the importance of Regulation 28 reports in identifying potential risks and supporting the shared objective of preventing future deaths. We are grateful for the careful consideration given to the evidence during the inquest and for bringing these matters formally to our attention. We acknowledge the Coroner’s concerns regarding differences in operational practice between police custody and HMPPS Prisoner Escort and Custody Services (PECS), particularly in relation to the management of detainees during toilet visits and the subsequent searching arrangements. Scope of HMPPS responsibility At the outset, it is important to clarify that HMPPS cannot offer a view or opinion on police custody practice, which operates under its own legal and policy framework. PECS suppliers are mandated to comply with HMPPS policy requirements, specifically those set out within the HMPPS External Escorts Framework, and do not exercise discretion to depart from those requirements. Supervision during toilet use HMPPS policy is explicit that, unless a prisoner is subject to a formally risk-assessed regime of constant supervision due to active suicide and/or self-harm risk, prisoners would not be supervised within toilet facilities in such close proximity to staff as to permit direct observation. HMPPS policy group have been engaged as part of this response and have formally supported that direct observation during use of toilet facilities, outside of exceptional and clearly evidenced safety risk scenarios, would be highly disproportionate, overly intrusive, and inconsistent with fundamental principles of dignity, privacy, and human decency. Such an approach would not align with HMPPS’s duty and obligations, human rights principles, or established HMPPS policy standards. Even in circumstances where constant supervision is justified due to acute safety risk, policy requires that the lowest level of intrusion compatible with safety is applied, with ongoing consideration of dignity and decency. Use of restraints and escort arrangements The HMPPS Directorate of Security have been consulted and jointly considered the issues raised and advises that the continued use of the escort chain, rather than standard handcuffs, remains a proportionate and appropriate control measure for HMPPS external escorts. Any requirement for closer observation or alternative restraint arrangements would only be considered reasonable and in very exceptional acute cases, where there is clear, current, and formally assessed evidence of such risk, and even then, must remain consistent with the principle of minimum necessary intrusion. Searching following toilet visits PECS recognises the concerns raised in relation to searching following toilet visits. In response, suppliers searching standard operating procedures have been reviewed and confirmed as compliant with HMPPS policy and the PECS ‘Authority’ have provided reflective direction and briefing around risk based searching to both PECS suppliers. HMPPS policy provides that, in these circumstances, a ‘fully clothed’ rub-down search is the appropriate and lawful method. It is acknowledged that, by their nature, such searches cannot eliminate all risk, and that in extreme and exceptional cases methods of secretion may remain undetectable despite proper application of the prescribed search procedures. This limitation is inherent and does not indicate a deficiency in policy or practice. Conclusion Having carefully considered the Coroner’s concerns, HMPPS concludes that: HMPPS policies are grounded in safety, proportionality, legality, and respect for decency and dignity. PECS suppliers are operating in accordance with mandated HMPPS policy and contractual requirements. Introducing routine direct observation during use of toilet facilities would be intrusive, disproportionate, and incompatible with established HMPPS policy standards. Accordingly, no changes to HMPPS policy or PECS operating procedures are proposed at this time. HMPPS remains committed to continuous review of policy where evidence supports the need for change, and we are grateful to the Coroner for highlighting these matters. We trust this response assists in discharging our duty under Regulation 28. Yours sincerely Senior Contract Manager Prisoner Escort and Custody Services
See every Prevention of Future Deaths report matching State Custody related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.