Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2026-0027, written 7 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Oct 2025 |
|---|---|
| Reference | 2026-0027 |
| Deceased | Angela Thompson |
| Coroner | Paul Marks |
| Coroner area | City of Kingston Upon Hull and the County of the East Riding of Yorkshire |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. His Majesty’s Prison & Probation Service (HMPPS) – Ministry of Justice 1 CORONER I am Professor Paul Marks, Senior Coroner, for the Coroner Area of City of Kingston Upon Hull and the County of the East Riding of Yorkshire. 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 29th April 2022, I commenced an investigation into the death of Angela Christine Thompson, aged 62 years. The investigation concluded at the end of the inquest on 22nd September 2025. The conclusion of the inquest was: SUICIDE 4 CIRCUMSTANCES OF THE DEATH Angela Christine Thompson was diagnosed with emotionally unstable personality disorder and had a long history of self-harm. She had been the subject of admissions under various sections of the Mental Health Act 1983. At the beginning of 2022, she received a 12-week custodial sentence and was released to an address in Hull on 6th April 2022. On that day, she was found lying on Sutton Road in an attempt to kill herself by being run over by the traffic. She was detained under S136 of the Mental Health Act 1983 and taken to Miranda House where she had a mental health assessment. This resulted in her being released from section and being offered support in the community. On 11th April 2022, she laid down in the road in the path of a lorry, which stopped in time to avoid a collision. She was again taken to Miranda House under S136 and had a further mental health assessment. She was offered informal admission, but declined, as in the past she had fund such admissions unhelpful. She was released from section. was Later that day, ran over by a taxi. She was attended by paramedics who continued resuscitation that had been started by bystanders and was conveyed to Hull Royal Infirmary. Despite the implementation of Advanced Trauma Life Support, she failed to rally and was declared deceased at 21:50 hours on 11th April 2022. There were no suspicious circumstances or third-party involvement surroundings. She knew that her actions would result in her death. 1 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 will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – Evidence was heard that in some instances within the prison estate of England and Wales, there may be a lack of liaison in patients who have on-going psychiatric issues at the time of release from custody between the prison medical services and the psychiatric services in the area where the released prisoner lives. This was felt to be of particular concern when a person is incarcerated at a prison geographically distant from their home address. Evidence suggested that such liaison would ensure and enhance continuity of care following release from prison. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation has the power to take such action. YOUR RESPONSE 7 You are under a duty to respond to this report within 56 days of the date of this report, namely by 2nd December 2025. 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 – Daughter; Humber Mental Health NHS Trust; Greater Persons; Manchester Mental Health NHS Services. I am also sending a copy to NHS England and equivalent organisations in the other countries of the United Kingdom. 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 7th October 2025 2
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.
9th January 2026
Probation Service (Yorkshire &
The Humber)
1 Burgage Square
Merchant Gate
WAKEFIELD
WF1 2TS
Professor Paul Marks,
Senior Coroner for the City of Kingston Upon Hull and the County
of the East Riding of Yorkshire
Dear Professor Marks,
Inquest Touching the Death of Angela Christine Thompson
I refer to your Regulation 28 Report issued following the Inquest into the death of Angela Thompson
and am issuing this response on behalf of HMPPS – Probation Service (Yorkshire & the Humber). I
know that you will share a copy of this response with her family, and I would like to take this
opportunity to express my sincere condolences for their loss.
Following the conclusion of the Inquest you raised a concern that
you had heard evidence that in some instances within the prison estate of England and Wales, there
may be a lack of liaison in patients who have on-going psychiatric issues at the time of release from
custody between the prison medical services and the psychiatric services in the area where the
released prisoner lives. This was felt to be of particular concern when a person is incarcerated at a
prison geographically distant from their home address. Evidence suggested that such liaison would
ensure and enhance continuity of care following release from prison.
The benefits of good multi-agency working are well established and the strategic direction for health
and justice is set out at a national level – Health and Justice Framework for Integration 2022 - 2025.
At an operational level, within HMPPS, there are now Regional Health & Justice Teams that sit within
Probation Community Integration. One of the aims of these teams is to work with NHS England,
Integrated Care Boards and Heads of Service in Probation to improve integrated health services for
anyone subject to Probation supervision, including prison leavers.
Multidisciplinary meetings are regularly held in relation to complex prisoners and those who engage in
self-harming behaviours, these are held with primary care, prison and community teams where
appropriate to formulate avenues of support during the transition from prison to the community.
It is acknowledged that a release from custody to a different geographical area is more complex and
learning from the circumstances of this sad death will be shared across all HMPPS Regions to ensure
liaison work can be reviewed and developed specifically to deal with this situation.
HMPPS has also created a central Deaths Under Supervision Team which supports the delivery of
learning across Prisons and Probation to develop confidence and skills to improve liaison between
prison and community teams and monitors the delivery of actions plans arising from PPO Reports to
ensure learning is embedded.
Thank you for bringing your concern to our attention and I hope that this response provides assurance
that action is being taken. This learning will be shared across HMPPS with each of the regional
Health & Justice Teams.
Yours sincerely,
Head of Community Integration
Probation (Yorkshire & the Humber)
9th January 2026
Probation Service (Yorkshire &
The Humber)
1 Burgage Square
Merchant Gate
WAKEFIELD
WF1 2TS
Professor Paul Marks,
Senior Coroner for the City of Kingston Upon Hull and the County
of the East Riding of Yorkshire
Dear Professor Marks,
Inquest Touching the Death of Angela Christine Thompson
I refer to your Regulation 28 Report issued following the Inquest into the death of Angela Thompson
and am issuing this response on behalf of HMPPS – Probation Service (Yorkshire & the Humber). I
know that you will share a copy of this response with her family, and I would like to take this
opportunity to express my sincere condolences for their loss.
Following the conclusion of the Inquest you raised a concern that
you had heard evidence that in some instances within the prison estate of England and Wales, there
may be a lack of liaison in patients who have on-going psychiatric issues at the time of release from
custody between the prison medical services and the psychiatric services in the area where the
released prisoner lives. This was felt to be of particular concern when a person is incarcerated at a
prison geographically distant from their home address. Evidence suggested that such liaison would
ensure and enhance continuity of care following release from prison.
The benefits of good multi-agency working are well established and the strategic direction for health
and justice is set out at a national level – Health and Justice Framework for Integration 2022 - 2025.
At an operational level, within HMPPS, there are now Regional Health & Justice Teams that sit within
Probation Community Integration. One of the aims of these teams is to work with NHS England,
Integrated Care Boards and Heads of Service in Probation to improve integrated health services for
anyone subject to Probation supervision, including prison leavers.
Multidisciplinary meetings are regularly held in relation to complex prisoners and those who engage in
self-harming behaviours, these are held with primary care, prison and community teams where
appropriate to formulate avenues of support during the transition from prison to the community.
It is acknowledged that a release from custody to a different geographical area is more complex and
learning from the circumstances of this sad death will be shared across all HMPPS Regions to ensure
liaison work can be reviewed and developed specifically to deal with this situation.
HMPPS has also created a central Deaths Under Supervision Team which supports the delivery of
learning across Prisons and Probation to develop confidence and skills to improve liaison between
prison and community teams and monitors the delivery of actions plans arising from PPO Reports to
ensure learning is embedded.
Thank you for bringing your concern to our attention and I hope that this response provides assurance
that action is being taken. This learning will be shared across HMPPS with each of the regional
Health & Justice Teams.
Yours sincerely,
Head of Community Integration
Probation (Yorkshire & the Humber)
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