Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0647, written 29 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 | 29 Dec 2025 |
|---|---|
| Reference | 2025-0647 |
| Deceased | Fallon Adams |
| Coroner | Simon Milburn |
| Coroner area | Cambridgeshire and Peterborough |
| Category | Alcohol, drug and medication related deaths |
| Organisation named | Northamptonshire Healthcare NHS Foundation Trust |
| 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 THIS REPORT IS BEING SENT TO: 1 Northamptonshire Healthcare NHS Foundation Trust 1 CORONER I am Simon MILBURN, Area Coroner for the coroner area of Cambridgeshire and Peterborough 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 Fallon Leanne ADAMS aged 37. The investigation concluded at the end of the inquest on 28 November 2025. The conclusion of the inquest was that: Fallon came to her death by intoxication of mixed drugs where the illicit obtaining of had a high probability of causing her death. Failure to conduct adequate welfare checks and observations allowed for missed opportunities to intervine. Evidence of this was staff admitting to not being able to confirm respiratory movement observations, observations of movement and general observations of inmate. Unsatisfactory training was also highlighted in the evidence however this did not cause or minimally contribute to Fallon's death. Fallon came to her death between 18:33 on the 8/2/23 and 7am on the 9/2/23. She came to her death on the top bunk of cell 8, wing B1 of HMP Peterborough. 4 CIRCUMSTANCES OF THE DEATH On Thursday 9th of February 2023 at approximately 0657hours, the alarm was raised by the cell mate of Ms ADAMS in her cell at HMP Peterborough. Staff arrived on scene and found Ms ADAMS unresponsive and cold to the touch, Regulation 28 – After Inquest Document Template Updated 30/07/2021 they called for an ambulance and an ambulance crew arrived and declared Ms ADAMS deceased at 0715hours after a negative heart trace. CPR had been attempted by Prison staff. Ms ADAMS had arrived at HMP Peterborough 8 days prior to her death and had been sharing a cell for the entirety of her time at the prison. Ms ADAM’s cell mate describes that during the days prior to her death, Ms ADAMS was and described her has “BEING OFF HER heavily medicated FACE MOST OF THE TIME”. Onthe day before her death, 8th of February 2023, Ms ADAMS’ states that during the evening, Ms ADAMS was lying on the top bunk and she was slouching over the top, she then fell off the bunk and hit her head. Ms ADAMS’ cell mate states that she then put Ms ADAMS to bed and tucked her in, she checked her head for injuries or lumps but could not see any. She last spoke to ADAMS at 1930hours when Ms ADAMS asked her if another prisoner had dropped off the laundry. Ms ADMA’s could be heard snoring until 2000hours when the cell mate herself fell asleep. Staff checked on the cell at 0559hours it was a visual check through the cell hatch, the officer recorded that he could see Ms ADAMS moving. Ms ADAMS’ cell mate woke at 0625hours and confirmed this was the time by turning on the TV in the cell. She shouted to Ms ADAMS to wake up but got no reply. She then went to check on her and touched her neck, she states it was cold, she then lifted her leg and describes it as a dead weight, she then raised the alarm and staff arrived on scene and began CPR. According to prison medical records , Ms ADAMS was on the following medications: Chlordiazepoxide 10mg Ibuprofen 400mg Mebeveine 135mg Methadone 1mg Metoclopramide 10mg Thiamine 100mg Sertraline 50mg 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise In my opinion there is a risk that future deaths could occur unless to concern. In the circumstances it is my statutory duty to report to you. action is taken. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Regulation 28 – After Inquest Document Template Updated 30/07/2021 Whilst an inmate at HMP Peterborough Fallon ADAMS was prescribed methadone (for opiate withdrawal) and chlordiazepoxide (for alcohol withdrawal). She also took non-prescribed obtained from an illicit source within the prison. All of these medications have a sedative effect which in combination have the potential to cause over sedation and death. apparently The evidence seemed to show that at no stage was Ms ADAMS given a specific warning or advice stating that taking additional non-prescribed medication/ could result in over sedation and death. I also heard evidence in relation to Regulation 28 issues. Whilst it is clear that a number of relevant changes were being made it was not clear that a specific warning in relation to the risks of over sedation was being implemented. 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 February 23, 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 – Legal representative for Ms ADAMS’ family – Legal representative for Sodexo – Legal representative for Northamptonshire Health Care 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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: 29/12/2025 Simon MILBURN Area Coroner for Cambridgeshire and Peterborough 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.
CHAIR AND CEO OFFICE Berrywood Hospital Berrywood Drive NORTHAMPTON NN5 6UD Ref: PFD Fallon Adams Date: 23rd February 2026 Mr S Milburn Area Coroner for Cambridgeshire and Peterborough Lawrence Court, Princes Street Huntingdon, PE29 3PA Dear Mr Milburn Regulation 28 Report Concerning Fallon Leanne Adams Thank you for your Report to Prevent Future Deaths (‘Report’) dated 29 December 2025 concerning the death of Fallon Leanne Adams between 8 and 9 February 2023. Before responding to the matters of concern you have included within your Report, I would like to express my condolences to Ms Adams’ family and loved ones. The matters of concern in your Report centre on the safeguards in place when prescribing medication in the prison setting. You highlighted the risk of interactions between prescribed and other medications, the warning or advice given by prescribers about such interactions, and that a specific warning in relation to the risks of oversedation has not yet been implemented. You have asked me either to provide details of action taken, or proposed to be taken, or to explain why no action is proposed. Accordingly, please find below my response to your concerns detailing the actions we will take to prevent future deaths. Advising patients on the risk of medication interactions The safe and effective use of medications within the secure environment is high priority for NHFT. We welcome the opportunity to learn from the circumstances surrounding Ms Fallon’s death to strengthen our approach. Cont’d/… Trust Headquarters: St. Mary’s Hospital, London Road, Kettering, NN15 7PW We agree it is important that a patient is informed about the risk(s) of any medication(s) our clinicians prescribe, including those that may arise from interactions with other medications they may be taking, whatever the source. In line with guidelines from the National Institute for Health and Care Excellence (NICE), we expect our prescribers to discuss a prescription with their patient. This will include advice on: the purpose of the prescribed medicine and what the patient can expect; how, when, and for how long to take the medicine; monitoring or follow-up requirements. the risks, potential side effects, and when/how to seek help; interactions with other medicines or lifestyle factors; and We expect our clinicians to take contemporaneous notes of their consultation(s) with patients, which would include a record of the advice they have provided alongside information on the prescription. We have taken the opportunity to remind prescribing clinicians working within the secure environment of our expectations concerning their discussions with patients and record keeping. Mitigating the risk of oversedation Requests for night sedation are frequent within the secure environment, particularly from patients with substance misuse problems, because those withdrawing from illicit drugs including cannabis, opiates, alcohol and benzodiazepines commonly experience insomnia. It is well known that insomnia may increase the risk of self-harm and suicide by negatively affecting mood, thoughts and behaviour, independently of other risk factors impacting on mental health. Whilst a non-pharmacological approach to the management of insomnia is recommended as the first line treatment, patients may require a prescription of hypnotic medication. Considering that it is also common for patients within the secure environment to be prescribed multiple medications, it is particularly important that our clinicians are equipped to assess, manage, and communicate the risks of over-sedation with their patient(s). Cont’d/… Trust Headquarters: St. Mary’s Hospital, London Road, Kettering, NN15 7PW Tel: 0300 027 1717 In response to your Report, we have reminded our prescribing clinicians of our expectations concerning the assessment and management of cumulative sedative burden, recognition of over-sedation, and the need for proactive escalation where concerns are identified. We have re-emphasised our expectations on documentation standards to ensure consistent and contemporaneous recording of clinical observations, including withdrawal assessments, blood pressure readings, and explicit confirmation where no signs of over-sedation are present. Staff have been reminded of the importance of repeating observations where results are unexpected and clearly documenting clinical judgement and escalation decisions. We have also introduced a new harm minimisation advice leaflet, which is now routinely provided to patients. This leaflet clearly outlines key risks, including polypharmacy, the use of illicit drugs alongside prescribed medication, the dangers of using substances alone in cells (particularly overnight), reduced tolerance following periods of abstinence, and the increased risk associated with medication initiation and titration periods. I hope the content of this letter fully addresses the concerns you raised in your Report and provides assurance on the steps we will take to prevent future deaths. Please contact me if you have any questions about this letter or require further information. Yours sincerely Chief Executive Cc Mrs Linda Chibuzor, Chief Nurse Mr David Maher, Managing Director and Deputy Chief Executive Dr Itai Matumbike, Chief Medical Officer Mrs Anne Rackham, Chief Operating Officer Interim Chair: Faisal Hussain Chief Executive: Angela Hillery Trust Headquarters: St. Mary’s Hospital, London Road, Kettering, NN15 7PW Tel: 0300 027 1717
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