Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0594, written 24 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 | 24 Nov 2025 |
|---|---|
| Reference | 2025-0594 |
| Deceased | Diana Grant |
| Coroner | Richard Travers |
| Coroner area | Surrey |
| Category | State Custody related deaths · Mental Health related deaths |
| Organisation named | Central and North West London NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Re : Diana Ocean Grant, Deceased
Regulation 28 Report to Prevent Future Deaths
Regulation 28 Report to Prevent Future Deaths
This Report is being sent to:
1.
2.
CEO, NHS England
Department of Health and Social Care.
The Secretary of State for the
1 CORONER
I am Richard Travers, HM Senior Coroner for Surrey.
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7 of Schedule 5 to the Coroners and Justice
Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations
2013.
3
INVESTIGATION and INQUEST
I commenced an investigation into the death of Diana Ocean Grant. The inquest,
which was heard with a jury, concluded on the 2nd April 2025 when the jury found
that the medical cause of death was:
Ia Cardio Respiratory Collapse
Ib Obstruction of Upper Airway by Foreign Body
and the jury’s conclusion as to the death was:
Diana Grant died as a result of putting a foreign object in her mouth which then
became lodged in her upper airway, in circumstances which cannot be ascertained,
whilst she was suffering a relapse of paranoid schizophrenia and symptoms of
psychosis.
Diana Grant’s death was possibly contributed to more than minimally by a failure
by the Community Mental Health Team to contact, assess, treat and manage her
between the 12th and 17th November 2021,
Diana Grant’s death was probably contributed to more than minimally by a failure
by the Psychiatric Liaison Team at St. Mary’s Hospital to request a Mental Health
Act Assessment or to conduct a mental health assessment by a doctor on the 17th
or 18th November 2021,
Diana Grant’s death was possibly contributed to more than minimally by a failure
by the Liaison and Diversion Psychiatric Service at Colindale Police Station to
request and await a Mental Health Act Assessment on the 18th November 2021,
and
Diana Grant’s death was probably contributed to more than minimally by a failure
by HMP Bronzefield to locate her in the health care unit and to open an ACCT
process following her detention in prison on the 19th November 2021.
I subsequently held a hearing, on the 11th November 2025, to receive evidence
relating to the prevention of future deaths.
4 CIRCUMSTANCES OF THE DEATH
The jury found as follows:
Diana Grant was diagnosed with paranoid schizophrenia in 2002. Her condition
was usually controlled by anti-psychotic medication. In 2021, the Community
Mental Health Team (CMHT) administered regular depot injections. Diana
suffered periodic relapses of her schizophrenia. It was known that Diana was at
risk of self-harming and risky behaviour when she was suffering a relapse (as
evidenced during previous relapses).
Diana started to inject weight loss drugs under the supervision of UCLH NHS
hospital clinic on the 14th October 2021, following a GP referral. The CMHT were
not informed that treatment had started. Diana informed the weight loss clinic
dietitian on the 1st November 2021 that she was hearing voices. The clinic did not
relay this information to the CMHT, neither was this discussed with the treating
consultant from the weight loss team.
Diana was exhibiting clear signs of a relapse in late October/November 2021
(signs reported were: blocking her mother’s calls, drinking more alcohol, and an
incident of taking her clothes off in a nightclub). She attended the CMHT on the
8th November 2021 to receive her depot injection and no signs of relapse were
noted.
On the 12th November 2021, Diana’s mother reported to the CMHT that she
thought Diana was suffering a relapse. The CMHT responded by making a note to
review her at the MDT meeting on the 16th November 2021. In this meeting the
consultant reported that Diana needed “to be reviewed soon”. Probably, a referral
to the First Response Team could have been made on the 12th November.
Probably, the reported concerns could have been made to the consultant more
urgently. These steps probably could have protected Diana at this stage. It could
have led to further mental health assessments.
On the 17th November 2021, Diana’s mother took her to the CMHT. It was judged
by the nurse that she needed to be in hospital. The only arrangement that was
made was for the First Response Team to see Diana the next day. Diana left the
CMHT suddenly while these arrangements were being made.
Before any assessment was made, Diana attacked her mother with a kitchen knife.
There is a probability that these actions were caused by her state of psychosis.
Following the attack, Diana was arrested by the police for attempted murder and
was taken to St. Mary’s Hospital where it was agreed that Diana needed a Mental
Health Act Assessment. A Mental Health Act Assessment should have been
conducted in the hospital. The Consultant and/or Registrar should have assessed
Diana in person.
There are several reasons why this did not happen: staff lack of clarity regarding
protocols, and unclear responsibilities and poor decision making by the
Psychiatric Liaison Team. There were also assumptions made without all the
appropriate information being accessed and shared. There were multiple
opportunities to initiate a Mental Health Act Assessment. The Approved Mental
Health Professional (AMHP) possibly could have asked for more information.
If the Mental Health Act Assessment had taken place in hospital, Diana probably
could have started treatment for her symptoms of relapse sooner and had increased
observations, possibly reducing her risk of self-harm, and possibly been diverted
from custody.
The Police probably should have utilised their powers under section 136 of the
Mental Health Act to detain Diana in a health-based place of safety. Diana was
taken from the hospital to Colindale Police Station custody in the early hours of
the 18th November 2021. She was then seen later that morning by the Liaison and
Diversion Service. The L&D nurse contacted the Barnet AMPH Team who
directed her to the Brent Team. There was no capacity for Diana to be assessed
that day for a Mental Health Act Assessment by that team. Diana was interviewed
and charged with attempted murder.
A member of the L&D team made her colleague at the Magistrates’ Court aware
of Diana and that she had not yet had a Mental Health Act Assessment with the
view that a referral could be before she went to court.
Diana was taken to Court and remanded into custody on the 19th November 2021.
If a Mental Health Act Assessment had been arranged before the court
appearance, Diana would possibly have been diverted to hospital instead of
prison. Diana was not seen at Court by the Liaison and Diversion (L&D) Service.
However, they made an urgent referral, via email, and followed this up with a
phone call to the Bronzefield Prison’s mental health in-reach team. The L&D
service also issued a self-harm/suicide warning form (SASH). This was handed to
SERCO.
This referral reached the general nurse and Operations Manager at the prison. The
referral requested: arranging an admission to the Health Care Unit and opening of
an Assessment, Care in Custody and Teamwork (ACCT).
Diana was taken to HMP Bronzefield and arrived on the early evening of the 19th
November 2021. The SASH and Person Escort Record were handed over and
received by the senior prison custody officer at the prison’s reception. The SASH
was misplaced and was not taken into account in the reception process.
The reception nurse accessed the referral email but did not take into account all
the email content which was available to him. He did not place Diana in the
Health Care Unit and he did not open an ACCT. He should have done both. Diana
was not seen by the reception Doctor. At no point in the reception process was an
ACCT opened and it should have been.
Diana was placed on ordinary location in cell D-23 on House Block 1. On her first
night, she was up all night, unsettled and screaming.
Diana was not seen by the prison General Practitioner on the 20th November 2021
because he had no contact details for her. He did not attempt to locate her. He did
not read all the relevant information available to him. Had he seen her, he
probably would have opened an ACCT and moved her to the Health Care Unit.
Diana would have benefitted from being in the Health Care Unit because the
nurses there were more familiar with mental health issues, there were fewer
residents, and there was more chance of communication between residents and
staff. She would have benefitted from being on an ACCT as this would have led to
more frequent observations.
None of the prison healthcare and operational staff were aware of the out-of-hours
mental health service available to the prison. If they had been, it probably would
have resulted in an out of hours referral for an assessment.
Whilst on the houseblock, Diana was screaming and shouting, running around,
and was behaving strangely in her cell. It is likely that she was experiencing
psychotic episodes.
Diana was locked in her cell at17.30 hours on the 20th November 2021. She was
last seen alive at 19.50 hours by a prison custody officer. The forensic evidence
suggests that Diana intentionally placed a foreign object (knickers) in her mouth.
We are unable to ascertain whether Diana intentionally put the object in her upper
airway.
At the time of her death, it is probable that Diana was in a state of psychosis and
was in a relapse of her schizophrenia and therefore we cannot ascertain her
intentions leading up to her death.
According to the forensic evidence, Diana died quickly due to her heart stopping
following stimulation of the vagus nerve.
Diana was found unresponsive in her cell at about 21.05 hours. It is likely she was
dead when she was found. Her death was formally declared at 21.47 hours.
5 CORONER’S CONCERNS
The evidence heard at the inquest raised a number of concerns that future deaths
could occur. I received extensive evidence addressing the issues arising, including
oral evidence at the hearing held on the 11th November 2025. As a result of that
evidence, all my concerns have been addressed by reason of changes which have
been made since the death, save for the concern below.
In my opinion, the following concern does continue and there is a continuing risk
that future deaths could occur unless action is taken. In the circumstances, it is my
statutory duty to report to you.
The MATTER OF CONCERN is as follows:
The concern arises in relation to persons who are judged to need immediate
admission to a mental health unit for assessment and/or treatment, but who are
also judged to need admission to a secure unit because they are dangerous to
others, whether by reason of being under arrest for, or charged with, a serious
criminal offence or otherwise.
The evidence I received established that, despite changes made since the
Deceased’s death, including the recent introduction of NHS England’s “Mental
Health Crisis Care for Londoners: London’s Section 136 Pathway and Health
Based Place of Safety Specification”, it remains extremely unlikely that such a
person will be granted immediate admission to a secure mental health unit. This is
principally because of the restricted capacity of the secure mental health unit
estate, but also because of an expectation that some element of pre-planning will
take place before such an admission occurs.
Consequently, for many persons in the circumstances described above, detention
in prison prior to transfer to a secure mental health unit continues to be
unavoidable. The evidence I heard at the inquest suggested that although the
expectation, in those circumstances, is that transfer from prison to hospital should
take place within 28 days, the low availability of beds actually results in transfers
taking, on average, as long as 80 to 90 days.
Detention in prison of persons requiring mental health unit admission raises a
concern for risk of death. The evidence I heard established that this is because a
mental health patient’s needs cannot be fully met in prison, even in a prison’s
health care wing. This is by reason of the fact that there is a material difference in
the physical environment, the nursing and therapeutic regimes, and the access to
psychological and other therapeutic treatments. Further, whilst medication and
treatment can be given compulsorily in hospital, that is not the case in prison.
The witness from whom I heard, stated that he was not aware of any work or
review currently being undertaken to address the lack of capacity within the
secure mental health unit estate or to address how the above risk may be resolved
or managed.
ACTION SHOULD BE TAKEN
6
In my opinion action should be taken to prevent future deaths by addressing the
concerns set out above and I believe your organisation has 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 the 19th January 2026. I, as 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:
a. The Mother of Diana Grant,
b. Central and North West London NHS Foundation Trust,
c. HM Prison and Probation Service,
d. HM Courts and Tribunal Service,
e. The Commissioner of Police of the Metropolis,
f. Sodexo Limited,
g. Nurse
,
h. Med-co Secure Healthcare Services Limited,
i. The City of Westminster, and
j. Prison and Probation Ombudsman.
I am also under a duty to send a copy of your response to the Chief Coroner.
I may also send a copy of your response to any other 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
24th November 2025 Richard Travers
2 responses 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.
Parliamentary Under-Secretary of State for Women’s Health and Mental Health 39 Victoria Street London SW1H 0EU HM Senior Coroner Richard Travers HM Coroner’s Court Surrey Station Approach Woking GU22 7AP 27 February 2026 Dear Mr Travers, Thank you for the Regulation 28 report of 24th November 2025 sent to the Department of Health and Social Care about the death of Diana Ocean Grant. I am replying as the Minister with responsibility for Women’s Health and Mental Health. Firstly, I would like to say how saddened I was to read of the circumstances of Diana’s death and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the delay in responding to this matter. Thank you for the additional time provided to the department to provide a response to the concerns raised in the report. Your report raises concerns that individuals assessed as requiring immediate admission to a secure mental health unit may nonetheless be detained in prison prior to transfer, owing principally to limited capacity within the secure mental health estate and the practical challenges associated with arranging emergency admissions. You further note the risks associated with detention in prison for those whose mental health needs cannot be fully met in that setting. In preparing this response, my officials have worked closely with NHS England to ensure that the concerns you raise are fully considered. NHS England has advised that, since April 2023, its South East Health and Justice team has commissioned the full healthcare provision at HMP Bronzefield, including primary care, substance misuse and mental health services. An independent review of healthcare provision at the prison was completed and submitted to the Prisons and Probation Ombudsman in February 2023, and an action plan was subsequently developed with the provider to address the findings. NHS England has confirmed that the London Region is satisfied that appropriate actions have been taken locally in response to the issues identified at inquest. To strengthen the sharing of critical information at the point of reception into custody, NHS England introduced a Single Point of Contact (SPoC) process at HMP Bronzefield in May 2024. This provides a dedicated NHS mailbox and telephone contact to enable timely transfer of complex medical and social care information from community services to prison healthcare teams. A Standard Operating Procedure has been issued to reception and healthcare staff, and compliance with the process is monitored through Liaison and Diversion contract review arrangements. NHS England has advised that this approach is being overseen regionally to reduce variation and mitigate first-night risk. At a national level, NHS England’s Adult Forensic Services Team is mapping emergency admission arrangements across all Adult Secure Provider Collaboratives, including out-of- hours access to forensic beds. This work is informing the development of a new national service specification for Access Assessment Services, which will include clear requirements for emergency admissions. A national database of referral and urgent contact information has also been established to support timely access to secure services. In addition, there is ongoing national work to address delays in transfers from prison to mental health hospitals, with a focus on reducing the time individuals spend in custody awaiting appropriate placement. NHS England has also established a Regulation 28 Working Group, bringing together regional medical and quality leaders to review Prevention of Future Death reports, identify emerging themes and ensure that learning is disseminated across the system. This will help to ensure that the lessons arising from Diana’s death are reflected in ongoing service improvement and patient safety work nationally. We remain committed to ensuring that people with severe mental illness receive care in the most clinically appropriate setting and that risks associated with custody are minimised wherever possible. Thank you again for drawing these important matters to my attention. I hope this response is helpful, and please do not hesitate to contact me should you require any further information. Yours sincerely, PARLIAMENTARY UNDER-SECRETARY OF STATE FOR WOMEN’S HEALTH AND MENTAL HEALTH
Richard Travers
HM Senior Coroner for Surrey
HM Coroner’s Court
Station Approach
Woking
GU22 7AP
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
t
11th February 2026
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Diana Ocean Grant who
died on 20th November 2021
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 24th
November 2025 concerning the death of Diana Ocean Grant on 20th November 2021.
In advance of responding to the specific concerns raised in your Report, I would like
to express my deep condolences to Diana’s family and loved ones. NHS England is
keen to assure the family and yourself that the concerns raised about Diana’s care
have been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise for
any anguish this delay may have caused Diana’s family or friends. I realise that
responses to Coroners’ Reports can form part of the important process of family and
friends coming to terms with what has happened to their loved ones, and I appreciate
this will have been an incredibly difficult time for them.
NHS England was not a party to the inquest, and we have therefore not had sight of
or heard the full extent of the witness evidence relating to the issues raised within
Sections 3 and 4 of your Report, which fall outside of NHS England’s role and remit.
However, we note you have stated at Section 5 that, as a result of the extensive
evidence received during the inquest, all of these issues were addressed by reason of
changes made since Diana’s death, save for one remaining concern.
The outstanding concern raised within Section 5 of your Report is that many people
are being detained in prison who require immediate admission to a secure mental
health unit. Their detention means that their needs are not fully met due to differences
in the physical environment, the nursing and therapeutic regimes and access to
psychological treatment between prisons and mental health units. You have raised
that this is principally due to the restricted capacity of the secure mental health unit
estate.
For completeness, NHS England’s London Region team have liaised with Central and
North West London NHS Foundation Trust’s Community Mental Health Team (CMHT)
in respect of some of the clinical issues raised throughout your Report. They have also
had sight of the witness evidence provided by the CMHT at inquest. The London
Region is satisfied that actions have been taken since Diana’s death, and ongoing
work is taking place, in order to avoid such issues arising again.
At the time of Diana’s death, the healthcare provision at HMP Bronzefield was
commissioned by Sodexo, with Mental Health services being commissioned by NHS
England. Since April 2023, NHS England’s South East Health and Justice team have
commissioned the whole healthcare prime provider model at HMP Bronzefield. This
includes all primary care services, substance misuse and mental health.
An independent review of the healthcare provision at HMP Bronzefield was
commissioned and submitted to the Prisons and Probation Ombudsman (PPO) in
February 2023. The PPO’s final report was published in January 2025. Alongside
Sodexo, the Clinical Lead for Central and North West London NHS Foundation Trust
was involved with developing an action plan in May 2023 and this was submitted to
the PPO.
Locally, NHS England’s South East Health and Justice Commissioning team and
Direct and Specialised Commissioning Quality team have engaged with the national
programme of mental health improvements, along with working with local providers,
to review areas that can cause delays to achieve the 28 day transfer target referred to
within your Report, including looking at the Who Pays guidance, escalation pathways,
referral forms and contact lists. There are also working groups with a focus on
alternatives to custody.
Single Point of Contact process
In addition, in May 2024, the Single Point of Contact (SPoC), otherwise known as the
Single Point of Access (SPA), was set up for HMP Bronzefield. This was implemented
to ensure that information from the community reaches the prison healthcare reception
team and is acted upon.
The SPoC process ensures that complex medical in confidence information and social
care needs can be received by prison healthcare in a timely manner and acted upon
ahead of a patient’s arrival in prison. It is recognised that, across the South East
Region, the current risk and complex medical information sharing arrangements
between prison healthcare and external stakeholders vary considerably. This poses a
risk to patient safety on a person’s first night in prison.
The SPoC process involves a generic NHS mailbox address for each South East
prison reception, for the purpose of information sharing, together with a read receipt
function and a prison healthcare phone number for more urgent cases. This inbox is
regularly monitored during the prison’s reception times. A Standard Operating
Procedure has also been communicated to all reception staff and wider healthcare
staff to outline this new process.
NHS England’s South East Region are assuring this new process via a data return
process in their Liaison & Diversion (L&D) contract review meetings. The L&D
providers submit information onto a tracker. One part of this tracker will identify how
prisons have responded to information shared via the SPoC. Trends will be picked up
if there are non-responses and those prisons will be approached.
National Forensic Services Work
NHS England’s Adult Forensic Services Team are currently mapping arrangements
across all 15 Adult Secure Provider Collaboratives for emergency admissions to an
adult forensic bed, including out of hours, to understand variation across England.
Using this information, and in collaboration with relevant stakeholders, we are
developing a new national service specification for Access Assessment Services (for
adult forensic services), that will include a requirement that arrangements are in place
for emergency admissions to an adult forensic bed, including out of hours.
We have also created a database of Access Assessment Services (for adult forensic
services) across England, that includes the direct contact information for referrals and
urgent referrals, and out of hours contact information. This has now been launched
and is accessible via the NHS Futures Collaboration Platform.
There is also an ongoing significant national programme of work to address delays in
transfers from prison to mental health hospitals.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors, and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of Diana,
are shared across the NHS at both a national and regional level and helps us to pay
close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
NHS England
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