Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0028, written 16 Jan 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Jan 2026 |
|---|---|
| Reference | 2026-0028 |
| Deceased | Wayne Walton |
| Coroner | Deborah Lakin |
| Coroner area | Coventry |
| 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.
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. , Associate Director of Nursing and Quality – Mental Health Directorate 1 CORONER I am Deborah Lakin, assistant coroner, for the coroner area of Coventry 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 4 On 12 January 2026 I commenced an investigation into the death of Wayne Pierce Walton, aged 45 years. The investigation concluded at the end of the inquest on 16 January 2026. The conclusion of the inquest was suicide, the date of death was 29 June 2024, the medical cause of death being asphyxiation. CIRCUMSTANCES OF THE DEATH The Deceased had been discharged from the Caludon Centre on 21 June 2024, where he had been an informal inpatient for a short period, having taken an overdose on 8 June 2024 with the intention of ending his life. The Deceased was discharged at his request on 21 June 2024, into the care of the community mental health Home Treatment Team, but he failed to engage and declined to attend for a 48 hour follow up appointment until 1 July 2024. The Deceased engaged sporadically with the Home Treatment Team and ultimately ended his life by asphyxiation on 29 June 2024. 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. 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] (1) Staff involved in the decision-making process for a patient’s discharge as an inpatient, into the care of the Home Treatment Team, were unaware of the policies applicable to the Home Treatment Team and were therefore unaware of the requisite information that should have been added into Risk Assessments and Safety Plans for the benefit of their colleagues in the Home Treatment Team. As risk assessment and risk formulation documentation had not been adequately completed, the Home Treatment Team were not able to identify a full and up to date risk analysis. Had the inpatient staff been aware of the importance of these documents for their colleagues’ benefit, in addition to the need for accurate completion for internal reasons, there was a risk that important information was not passed on. (2)There is in existence, a policy entitled “Personal Relationships at Work” which addresses personal relationships of a particular type, but which does not address the potential for a conflict of interest when a member of staff, or a person shadowing a member of staff, recognises that they may know a patient other than because of a personal relationship as envisaged in the aforementioned policy. The absence of guidance on how to manage this situation, may place both the member of staff and the patient at risk of harm. 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 9 March 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 :Next of kin and Coventry City Council. 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 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. 9 16 January 2026 Deborah R Lakin
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.
Our Ref: Wayne Pierce Walton 9 March 2026 Ms Deborah R Lakin, HM Assistant Coroner, The Coroner's Office, Coventry City Council, Manor House Drive, Coventry, CV1 2ND Dear Ms Lakin, Re: Inquest touching the death of Mr Wayne Pierce Walton I am writing to you in response to the Regulation 28: Prevention of Future Deaths Report, which was received from your office on 19 January 2026, following the inquest conducted in respect of the death Mr Wayne Pierce Walton. Staff from the Trust were grateful for the opportunity to give evidence at the inquest, including sharing our work to improve the care and safety of those who use our services. Your summary of the inquest included reference to key points, which were raised by yourself and members of Mr Walton’s family, and for which you requested the Trust consider and provide a response back to you. I have set out the two points and a response below. 1. Staff involved in the decision-making process for a patient’s discharge as an inpatient, into the care of the Home Treatment Team, were unaware of the policies applicable to the Home Treatment Team and were therefore unaware of the requisite information that should have been added into Risk Assessments and Safety Plans, for the benefit of their colleagues in the Home Treatment Team. As risk assessment and risk formulation documentation had not been adequately completed, the Home Treatment Team were not able to identify a full and up to date risk analysis. Had the inpatient staff been aware of the importance of these documents for their colleagues’ benefit, in addition to the need for accurate completion for internal reasons, there was a risk that important information was not passed on. Our investigatory work from the Patient Safety Incident Investigation (PSII) report PSII2172, focused on learning and improvement, ensuring staff are supported to understand the processes to embed effective documentation of a person’s risk, as well as Trust processes to support safe discharge and/or transition between services. We are revising our Standard Operating Procedure (SOP) for Internal Transfers within Adult and Older Adults Mental Health Services (version 5), to reflect the function and structure of the new Electronic Patient Record (EPR) system (SystmOne), and provide clearer guidance on the agreed date of handover of care, the continuation and ownership of care packages during transfer, and the requirement for a joint handover meeting between teams, with an agreed date understood by all. Once ratified, we shall audit our internal transfers between teams to assess compliance, as well as any further opportunities to gain experience, on an ongoing basis. You will be aware that staff who attended the inquest, shared examples of the improvement work services are engaged in, which I have set out below, alongside other developments which I feel important to share, as part of a comprehensive response. Clinical Risk Assessment The Trust is one of ten organisations nationally participating in the National Collaboration Centre for Mental Health programme, supported by the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) and led by NHS England (November 2024 to March 2026). This programme focuses on the co-production of personalised inpatient safety planning, ensuring our local approach is shaped by national evidence, expert guidance, and the lived experience of patients and carers (Appendix 1). As part of this work, the Trust has launched the updated Risk and Safety section within the EPR, supported by a demonstration package and quick reference guide to assist staff in embedding the new approach into practice. This enhancement strengthens clinical safety, improves the quality of documentation, and aligns practice to national guidance. To ensure the system is delivering the intended quality and safety benefits, our next steps, following the EPR launch, are to: (cid:127) Repeat the audit, which will assess alignment to Staying Safe guidance and measure the impact of the new system on documentation and practice (cid:127) Receive feedback from patients and staff, collecting, analysing and reporting feedback from patients regarding involvement in safety planning, alongside staff confidence and usability data Implement iterative improvement of documentation, learning from post-launch feedback to inform further refinements to the EPR templates and workflows, to maximise effectiveness and ease of use. (cid:127) Discharge Planning The Trust has a clear and well-governed framework in place, to support the safe and effective discharge of patients from its inpatient mental health services. Discharge planning commences on admission and is overseen through regular multi-disciplinary team (MDT) review, with crisis teams routinely involved to support early identification of needs and safe transition. The process is guided by the Trust’s Discharge from Inpatient Mental Health Wards SOP (V1.1, February 2025) and the Trust’s Bed Management Policy, which set out defined responsibilities, standards, and safety requirements, to ensure consistency across all wards. The Trust systematically reviews patient and carer feedback and incidents which staff report, to support monitoring the quality of discharge planning and application. A structured audit, aligned to the Discharge from Inpatient Mental Health Wards SOP, has been introduced to provide additional assurance regarding the quality of documentation, safety planning, and involvement of patients and their families or carers (Appendix 2). Collectively, these arrangements ensure safe, effective, and well-governed processes in place to support safe discharges. Regarding the second point you raised with the Trust: Page: 2 of 7 2. There is in existence, a policy entitled “Personal Relationships at Work” which addresses personal relationships of a particular type, but which does not address the potential for a conflict of interest when a member of staff, or a person shadowing a member of staff, recognises that they may know a patient other than because of a personal relationship as envisaged in the aforementioned policy. The absence of guidance on how to manage this situation, may place both the member of staff and the patient at risk of harm. In developing our response, it is important to acknowledge the clinical context in which practitioners may operate, when caring for individuals with complex needs and often social circumstances which can be challenging. Clinicians are required to balance risk, need, and individual preference, whilst working within dynamic and, sometimes, unpredictable environments. The Nursing and Midwifery Council (NMC) Code (2015) establishes firm professional standards acknowledging that nurses must apply their professional judgment and discretion when making decisions in circumstances which may be complex, time-pressured, or unprecedented. This includes adapting care approaches to meet specific needs of the individual, provided such decisions are evidence-based, clearly reasoned, and demonstrably in the person’s best interests. The Trust has introduced an addendum to strengthen existing governance arrangements and provide clearer guidance for staff (Appendix 3), included as an appendix to the existing Personal Relationships at Work policy. It introduces a clear process for managing situations in which staff recognise patients through non-personal prior acquaintance, such as community links, former workplaces, school settings, or casual social connections and aims to support in ensuring professional boundaries are maintained and care remains impartial, safe, and centred on the patient’s best interests. The guidance strengthens organisational expectations around professional boundaries, reminding staff to pause, assess risk, notify managers, and follow agreed escalation pathways whenever prior community or social links could impact safe and objective care. The guidance applies to all staff groups, including students and observers, and is underpinned by the NHS shared decision making principles, and expectations for confidentiality and staff wellbeing. I trust the above provides you with further assurance that the Trust has responded to the findings of the inquest. We will continue to take the opportunity to gain experience from safety events in healthcare and to support the coroner’s office to conduct their inquest responsibilities. Yours sincerely, , Interim Chief Nursing Officer, CWPT Copy: Herefordshire and Worcestershire , Chief Nursing Officer, NHS Coventry and Warwickshire and NHS Page: 3 of 7
Our Ref: Wayne Pierce Walton 9 March 2026 Ms Deborah R Lakin, HM Assistant Coroner, The Coroner's Office, Coventry City Council, Manor House Drive, Coventry, CV1 2ND Dear Ms Lakin, Re: Inquest touching the death of Mr Wayne Pierce Walton I am writing to you in response to the Regulation 28: Prevention of Future Deaths Report, which was received from your office on 19 January 2026, following the inquest conducted in respect of the death Mr Wayne Pierce Walton. Staff from the Trust were grateful for the opportunity to give evidence at the inquest, including sharing our work to improve the care and safety of those who use our services. Your summary of the inquest included reference to key points, which were raised by yourself and members of Mr Walton’s family, and for which you requested the Trust consider and provide a response back to you. I have set out the two points and a response below. 1. Staff involved in the decision-making process for a patient’s discharge as an inpatient, into the care of the Home Treatment Team, were unaware of the policies applicable to the Home Treatment Team and were therefore unaware of the requisite information that should have been added into Risk Assessments and Safety Plans, for the benefit of their colleagues in the Home Treatment Team. As risk assessment and risk formulation documentation had not been adequately completed, the Home Treatment Team were not able to identify a full and up to date risk analysis. Had the inpatient staff been aware of the importance of these documents for their colleagues’ benefit, in addition to the need for accurate completion for internal reasons, there was a risk that important information was not passed on. Our investigatory work from the Patient Safety Incident Investigation (PSII) report PSII2172, focused on learning and improvement, ensuring staff are supported to understand the processes to embed effective documentation of a person’s risk, as well as Trust processes to support safe discharge and/or transition between services. We are revising our Standard Operating Procedure (SOP) for Internal Transfers within Adult and Older Adults Mental Health Services (version 5), to reflect the function and structure of the new Electronic Patient Record (EPR) system (SystmOne), and provide clearer guidance on the agreed date of handover of care, the continuation and ownership of care packages during transfer, and the requirement for a joint handover meeting between teams, with an agreed date understood by all. Once ratified, we shall audit our internal transfers between teams to assess compliance, as well as any further opportunities to gain experience, on an ongoing basis. You will be aware that staff who attended the inquest, shared examples of the improvement work services are engaged in, which I have set out below, alongside other developments which I feel important to share, as part of a comprehensive response. Clinical Risk Assessment The Trust is one of ten organisations nationally participating in the National Collaboration Centre for Mental Health programme, supported by the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) and led by NHS England (November 2024 to March 2026). This programme focuses on the co-production of personalised inpatient safety planning, ensuring our local approach is shaped by national evidence, expert guidance, and the lived experience of patients and carers (Appendix 1). As part of this work, the Trust has launched the updated Risk and Safety section within the EPR, supported by a demonstration package and quick reference guide to assist staff in embedding the new approach into practice. This enhancement strengthens clinical safety, improves the quality of documentation, and aligns practice to national guidance. To ensure the system is delivering the intended quality and safety benefits, our next steps, following the EPR launch, are to: (cid:127) Repeat the audit, which will assess alignment to Staying Safe guidance and measure the impact of the new system on documentation and practice (cid:127) Receive feedback from patients and staff, collecting, analysing and reporting feedback from patients regarding involvement in safety planning, alongside staff confidence and usability data Implement iterative improvement of documentation, learning from post-launch feedback to inform further refinements to the EPR templates and workflows, to maximise effectiveness and ease of use. (cid:127) Discharge Planning The Trust has a clear and well-governed framework in place, to support the safe and effective discharge of patients from its inpatient mental health services. Discharge planning commences on admission and is overseen through regular multi-disciplinary team (MDT) review, with crisis teams routinely involved to support early identification of needs and safe transition. The process is guided by the Trust’s Discharge from Inpatient Mental Health Wards SOP (V1.1, February 2025) and the Trust’s Bed Management Policy, which set out defined responsibilities, standards, and safety requirements, to ensure consistency across all wards. The Trust systematically reviews patient and carer feedback and incidents which staff report, to support monitoring the quality of discharge planning and application. A structured audit, aligned to the Discharge from Inpatient Mental Health Wards SOP, has been introduced to provide additional assurance regarding the quality of documentation, safety planning, and involvement of patients and their families or carers (Appendix 2). Collectively, these arrangements ensure safe, effective, and well-governed processes in place to support safe discharges. Regarding the second point you raised with the Trust: Page: 2 of 7 2. There is in existence, a policy entitled “Personal Relationships at Work” which addresses personal relationships of a particular type, but which does not address the potential for a conflict of interest when a member of staff, or a person shadowing a member of staff, recognises that they may know a patient other than because of a personal relationship as envisaged in the aforementioned policy. The absence of guidance on how to manage this situation, may place both the member of staff and the patient at risk of harm. In developing our response, it is important to acknowledge the clinical context in which practitioners may operate, when caring for individuals with complex needs and often social circumstances which can be challenging. Clinicians are required to balance risk, need, and individual preference, whilst working within dynamic and, sometimes, unpredictable environments. The Nursing and Midwifery Council (NMC) Code (2015) establishes firm professional standards acknowledging that nurses must apply their professional judgment and discretion when making decisions in circumstances which may be complex, time-pressured, or unprecedented. This includes adapting care approaches to meet specific needs of the individual, provided such decisions are evidence-based, clearly reasoned, and demonstrably in the person’s best interests. The Trust has introduced an addendum to strengthen existing governance arrangements and provide clearer guidance for staff (Appendix 3), included as an appendix to the existing Personal Relationships at Work policy. It introduces a clear process for managing situations in which staff recognise patients through non-personal prior acquaintance, such as community links, former workplaces, school settings, or casual social connections and aims to support in ensuring professional boundaries are maintained and care remains impartial, safe, and centred on the patient’s best interests. The guidance strengthens organisational expectations around professional boundaries, reminding staff to pause, assess risk, notify managers, and follow agreed escalation pathways whenever prior community or social links could impact safe and objective care. The guidance applies to all staff groups, including students and observers, and is underpinned by the NHS shared decision making principles, and expectations for confidentiality and staff wellbeing. I trust the above provides you with further assurance that the Trust has responded to the findings of the inquest. We will continue to take the opportunity to gain experience from safety events in healthcare and to support the coroner’s office to conduct their inquest responsibilities. Yours sincerely, Interim Chief Nursing Officer, CWPT Copy: Herefordshire and Worcestershire , Chief Nursing Officer, NHS Coventry and Warwickshire and NHS Page: 3 of 7 Appendix 1: Staying Safe from Suicide: CWPT Strategic Delivery Plan 2024-26 Drivers for change: NICE guidance NG225- Self Harm: assessment, management and preventing recurrence (September 2022) (cid:127) Risk assessment tools and scales to predict future suicide or repetition of self-harm should not be used (cid:127) Risk assessment tools and scales to determine who should and should not be offered treatment or who should be discharged should not be used (cid:127) Global risk stratification in low, medium, or high to predict future suicide or repetition of self-harm should not be used (cid:127) Global risk stratification into low, medium, or high to determine who should be offered treatment or who should be discharged should not be used (cid:127) There should be a move to risk formulation and safety planning from assessment alone Letters from NHSE to NHS professional leads and education providers to seek assurance that clinical staff adherent to NG225 (2022/2023) Health Services Safety Investigations Body (HSSIB) (Sept 2024) interim report; Creating conditions of learning from deaths and near misses in inpatient and community mental health services: Assessment of suicide risk and safety planning: In summary findings were (cid:127) The use of risk assessment tools that provide a high, medium, or low risk score is no longer acceptable but continue to be used (cid:127) Patients who had expressed suicidal thinking, and their families and carers said that they were not (cid:127) listened to when sharing their safety needs and their perceptions of risk were disregarded Investigations into death by suicide and near misses often refer to questions and evidence associated with high, medium, and low risk stratification, including coroners’ investigations and serious incident investigations (cid:127) Staff described a fear of being blamed if a risk assessment, including risk stratification is not completed and the patient later comes to harm (cid:127) Some digital patient record systems still require staff to categorise risk assessments as high, medium, or low risk (cid:127) Successful implementation of person centered approached to patient safety assessment and safety planning is dependent on many factors including an organisation’s leadership culture, the people that work within organisations and the emphasis on involving the patient and their families and carers, in the assessment and planning processes (cid:127) Organisations have involved ‘digital experts’ in their electronic patient record systems improvement projects. NHS England guidance to support implementation of NG225 expected March 2024 now expected March 2025. CWPT is one of 10 Trusts part of a National Collaboration Centre for Mental Health (supported by NCISH and led by NHSE) to co-produce personalised approaches to safety planning in inpatient settings (November 2024- March 2026) Safety planning is a priority in Patient Safety Incident Response Framework, and this work will link to the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Page: 4 of 7 Appendix 2: Discharge from Inpatient Mental Health Wards - SOP Audit Questions V0.1 Page: 5 of 7 Appendix 3: Professional Boundaries: Prior Acquaintance with Service Users Professional Boundaries: Prior Acquaintance with Service Users STOP & PAUSE If you recognise a patient through a community, school, workplace, or social media link: (cid:127) STOP before beginning any care. (cid:127) Ask yourself if involvement may impact judgement, comfort, confidentiality, or boundaries. (cid:127) If YES or UNSURE: Do NOT proceed. INFORM YOUR MANAGER Inform your manager immediately. They will assess risk, decide on reassignment, and document appropriately. (Do not place staff details in patient notes unless clinically essential.) DO NOT DISCUSS DETAILS Do NOT mention how you know the patient. Do NOT discuss the situation outside proper reporting lines. Do NOT engage with the patient on social media links. WHAT TO SAY TO THE PATIENT Use a neutral explanation: "We are ensuring the most appropriate member of staff is available to support your care today." STUDENTS (cid:127) OBSERVERS (cid:127) SHADOWERS Follow the same steps. Inform supervisor immediately. Step back if uncomfortable or unsure. ESCALATE IF: (cid:127) Boundary concerns persist. (cid:127) The patient expresses discomfort. (cid:127) There is risk of confidentiality breach or harm. QUICK CHECK BEFORE PROCEEDING ■ No conflict of interest ■ No discomfort for staff or patient ■ Boundaries intact ■ Manager consulted ■ Decision documented Page: 6 of 7 Scenario Guidance – Quick Reference Scenario A – Local Club Acquaintance Pause → do not mention link → contact manager → withdraw if any boundary concern. Scenario B – Address Linked to Former Family Friends Pause → discuss with manager → proceed only if low risk → document decision. Scenario C – Social Media Connection Pause → avoid referencing social media → inform manager if uncomfortable → withdraw if needed. Scenario D – Parent from Child’s School Pause → consider confidentiality/sensitivity → discuss with manager → withdraw if discomfort exists. Scenario E – Historic Tension Do NOT proceed and review visit/contact → inform manager → reallocate care immediately Page: 7 of 7
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