Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0593, 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 | 2025-0593 |
| Deceased | Jack Brown |
| Coroner | Sophie Lomas |
| Coroner area | Northamptonshire |
| Category | Hospital Death (Clinical Procedures and medical management) 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 Secretary of State for Health and Social Care 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 10 February 2023 I commenced an investigation into the death of Jack Richard BROWN aged 86. The investigation concluded at the end of the inquest on 24 October 2025. The conclusion of the inquest was that Mr Brown died due to natural causes. 4 CIRCUMSTANCES OF THE DEATH Mr Brown was an 86 year old gentleman who had been admitted to a care home following a hospital stay for heart failure and hyponatraemia. He was suffering from delirium and required constant 1:1 observations, along with help with all activities of daily living. Against that background, on the evening of 25th January 2023 Jack was assisted to the toilet by the night carer. He was sleepy and indicated that he wanted to stay on the toilet. He remained on the toilet asleep between approximately 9.30pm and 7.30am. Attempts were made during that time to rouse him but he remained asleep. At 8am on 26th January 2023 a handover of care staff took place and the day carer raised a concern that Mr Brown was unresponsive. Further staff checked Mr Brown and recognised that he had sadly died. His death was confirmed by paramedics who attended the scene. A post-mortem examination concluded that Mr Brown had died due to ischemic heart disease. 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) At the inquest the court heard evidence that care agencies who provide agency care staff to care / nursing homes do not need to register with the CQC and are not regulated by any other body. The activites of such agencies are therefore not inspected or checked to ensure that they have rigerous recruitment processes and there is no one to report matters to when a concern is identified. This gives rise to a concern as care homes may rely on agencies to vet agency carers and Regulation 28 – After Inquest Document Template Updated 30/07/2021 have minimal input into suitability and training for the role. This creates a risk that agency care staff, who may be wholly unsuitable for the role, are providing care to vulnerable people without basic checks as to experience and suitability. This places service users at risk of harm and gives rise to a risk that future deaths could occur. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons The family of Jack Brown I have also sent it to Care Quality Commission (CQC) 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 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.
Minister of State for Care 39 Victoria Street London SW1H 0EU 8th January 2026 Sophie Lomas HM Assistant Coroner The Guildhall St Giles’ Square Northampton NN1 1DE Dear Ms Lomas, Thank you for the Regulation 28 report of 18 November 2025 sent to the Secretary of State of the Department of Health and Social Care about the death of Mr Jack Richard Brown. I am replying as the Minister with responsibility for Adult Social Care (ASC). Firstly, I would like to say how saddened I was to read of the circumstances of Mr Brown’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Your report raises concerns that because care agencies, who supply agency care staff to care and nursing homes, are not regulated by the Care Quality Commission (CQC), there is a risk that agency care staff “are providing care to vulnerable people without basic checks as to experience and suitability”, which “places service users at risk of harm”. In preparing this response, my officials have made enquiries with the CQC to ensure we adequately address your concerns. Matters of concern: • At the inquest the court heard evidence that care agencies who provide agency care staff to care / nursing homes do not need to register with the CQC and are not regulated by any other body. The activities of such agencies are therefore not inspected or checked to ensure that they have rigorous recruitment processes and there is no one to report matters to when a concern is identified. This gives rise to a concern as care homes may rely on agencies to vet agency carers and have minimal input into suitability and training for the role. This creates a risk that agency care staff, who may be wholly unsuitable for the role, are providing care to vulnerable people without basic checks as to experience and suitability. This places service users at risk of harm and gives rise to a risk that future deaths could occur. Care providers are required to be registered with the CQC where they carry out a regulated activity – as described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. However, employment agencies do not usually carry out regulated activity and as such do not typically need to be registered. Care homes and nursing homes do typically carry out regulated activity and therefore are registered with CQC. CQC requires all health and social care providers registered with them to deploy enough suitably qualified, competent and experienced staff (including both registered and unregistered professionals) to enable them to meet all other regulatory requirements described in Regulation 18 Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These regulations apply to providers who recruit care staff via employment agencies. It is the responsibility of the regulated provider to ensure robust and safe recruitment practices are in place, and to make sure that all staff, including agency staff, are suitably experienced, competent and able to carry out their role. Providers must also ensure staff receive appropriate training and supervision, and are supported to obtain further qualifications. Staff who are registered with a health care or social care regulator, including health care professionals, social workers or other professionals, must be supported to provide evidence to the appropriate regulator to show that they meet the professional standards needed to continue to practise. Whilst individual care workers, including agency staff, are expected to act competently and in line with regulations, the legal duty to comply with CQC regulations sits with the registered provider and registered manager. CQC cannot prosecute for a breach of Regulation 18, but CQC can take regulatory action such as issuing a warning notice to the provider to make improvements. Further to those regulatory safeguards, the department is committed to enhancing the skills of staff working in adult social care, including those employed by agencies. It is vital to ensure that the care provided is of good quality, fair, personalised, and accessible. The department is supporting the professionalisation of the workforce through a range of activities which agencies can access for their employees. We recently revised and expanded the Care Workforce Pathway, the first national career structure for adult social care. This sets out the knowledge, skills, values, and behaviours needed to work in the sector and provides a framework for progression and development. The department also launched the Adult Social Care Learning and Development Support Scheme in September 2024, backed by up to £12 million this financial year for eligible care staff to undertake courses and qualifications, including the new Level 2 Adult Social Care Certificate. Developed from the Care Certificate standards, the Level 2 Adult Social Care Certificate has been designed to support people in care roles to have the most up to date knowledge and baseline skills required to support people to succeed in their roles. To ensure training undertaken is of good quality, we also launched the Quality Assured Care Learning Service which supports individuals and employers to easily identify trusted learning and development opportunities which meet the needs of the sector. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MINISTER OF STATE FOR CARE
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