Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0624, written 11 Dec 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Dec 2025 |
|---|---|
| Reference | 2025-0624 |
| Deceased | Katherine Wright |
| Coroner | Nicholas Graham |
| Coroner area | Oxfordshire |
| Category | Alcohol, drug and medication related deaths · Police 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 FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Constable, Thames Valley Police 1 CORONER I am Nicholas Graham, HM Area Coroner for Oxfordshire, c/o Oxfordshire Coroner’s Office, 1 Tidmarsh Lane, Oxford OX1 1NS 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 3 January 2024, I commenced an investigation into the death of Katherine Wright, known as Sarah, aged 60. The investigation concluded at the end of the inquest on 4 December 2025. The conclusion of the inquest was a Narrative Conclusion: Sarah Wright was found deceased at her home address on 20 December 2023. She had a long-standing history of chronic alcohol misuse. Concerns for her welfare were raised on 15 December 2023 and police attended her address on 16 December 2023 but did not locate her. She was subsequently found deceased on 20 December 2023 following a further search of her address. Post-mortem examination and toxicological tests revealed no traumatic injuries or natural causes for her death, but tests did confirm significant alcohol levels. Her death was likely caused by sudden unexpected death in the context of alcohol misuse. It has not been possible to determine on the evidence when Sarah died and whether, if she had been found earlier, she would have survived. 4 CIRCUMSTANCES OF THE DEATH Sarah Wright was reported missing on 15 December 2023. Thames Valley Police officers attended her flat on 16 December 2023, forced entry, and conducted a search but did not locate her. She was later found deceased in the same flat on 20 December 2023, during a second search. The Professional Standards investigation and evidence at the inquest confirmed that the initial search was inadequate. The officer who undertook the bedroom search cited concerns about personal safety due to the cluttered condition of the room but did not escalate these concerns. The family were informed that a thorough search had been completed. 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. The matters of concern are as follows: 1. Lack of training and guidance for frontline officers on conducting searches of premises in missing person cases. Evidence given by the Police at the Inquest indicated that there is no structured training or clear operational guidance on what constitutes an adequate search, including checking all areas of a property where a person could reasonably be found. 2. Absence of protocols for escalating safety concerns during searches. The officer who undertook the search felt unsafe due to the cluttered environment but did not escalate this concern or request additional resources to enable an adequate search to be carried out. There appears to be no guidance on when and how officers should escalate such issues. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths 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 5th February 2026. 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: • Sarah Wright’s family 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. 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 09 December 2025 Mr Nicholas Graham, Area Coroner for Oxfordshire
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.
Chief Constable Thames Valley Police HQ Oxford Road Kidlington OX5 2NX 3rd February 2026 Mr Nicholas Graham HM Area Coroner for Oxfordshire c/o Oxfordshire Coroner’s Office 1 Tidmarsh Lane Oxford OX1 1NS Dear Nicholas, Inquest into the Death of Katherine Wright, Known as Sarah Thank you for your report in respect of circumstances surrounding the tragic death of Sarah sent, under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, by letter dated 9th December 2025. It is with much regret that I would confirm the initial search for Sarah was not conducted to the standards I would expect from my officers. Thames Valley Police (TVP) is committed to learning from this incident and to taking all necessary steps to improve the standard of searching in similar circumstances. I respond below to the matters of concern raised. Absence of structured guidance for officers undertaking premises searches during missing person investigations. To address this, we have reviewed our Missing Persons Operational Guidance and included a new section dedicated to the searching of premises for missing persons. This includes sub sections on the extent of the search; equipment and resources that may be used including the use of personal protective equipment; potential hazards and how the Specialist Search Unit may be used to advise and mitigate such hazards. The source documents used to create this section include a College of Policing e-learning package ‘Searching Premises’ and an input for all new recruits on Specialist Police Search Advisors. This new guidance has been shared with our Learning and Development department and will be integrated into Foundation Training for new recruits. It has also been shared with all officers in a force wide communication. Absence of protocols for escalating safety concerns during searches Your report concerns arise during a premises search. identified an absence of clear escalation processes where hazards or safety The new Premises Search Guidance directly addresses this by setting out options for officers 1 when encountering hazards and specifying supervisory and PolSA escalation requirements. This ensures officers do not conduct searches beyond their training or in unsafe conditions. I am satisfied that the measures outlined above provide a comprehensive and durable response to the matters of concern raised in your Regulation 28 Report. The introduction of dedicated premises search guidance, its integration into missing persons operational guidance and the force-wide communication of these changes will strengthen TVP’s response to missing person investigations. Please do not hesitate to contact me should you require any further information. Yours Sincerely Chief Constable Thames Valley Police 1
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