Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0066, written 6 Feb 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Feb 2026 |
|---|---|
| Reference | 2026-0066 |
| Deceased | Paul Thompson |
| Coroner | Darren Stewart |
| Coroner area | Suffolk |
| Category | Suicide (from 2015) |
| 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: 1 reducing Offending 1 CORONER Minister of State for Prisons, Probation and I am Darren STEWART OBE, HM Area Coroner for the coroner area of Suffolk 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 25 July 2024 I commenced an investigation into the death of Paul Christoper THOMPSON aged 53. The investigation concluded at the end of the inquest on 04 December 2025. The conclusion of the inquest was: Suicide The medical cause of death was confirmed as: 1a Multiple Injuries 4 CIRCUMSTANCES OF THE DEATH On 15th July 2024 at around 17.39 hours at Elmswell Railway Station, Paul Christoper THOMPSON was observed which then struck Mr. THOMPSON causing his death. Police and ambulance attended and confirmed Mr. THOMPSON's death. Mr. THOMPSON’s previous medical history included suffering from the condition of functional neurological disorder which had profoundly impacted on his life leading to the ending of his employment and him subsequently developing anxiety, depression and alcohol dependency. Since 27th March 2024, Mr. THOMPSON had been remanded in custody at HMP Norwich. During his time in custody Mr. THOMPSON had expressed suicidal ideation and been under the care of prison mental health services, appearing on occasions anxious and depressed. Mr. THOMPSON's suicidal ideation included thoughts of taking his own life by stepping into the path of an oncoming train. He had been placed on Assessment, Care in Custody and Teamwork (ACCT) care planning process during his time in custody which had resulted in a stabilisation of his condition and reduction in suicidal ideation. His care and treatment by prison mental health services was ongoing at the time of his release. On the 11th July 2024 Mr. THOMPSON appeared before Suffolk Magistrates Court Regulation 28 – After Inquest Document Template Updated 30/07/2021 and was sentenced to 12 weeks custody which equated to the time he had served in prison up until that point. His immediate release was therefore directed. Returning to HMP Norwich late in the day, Mr. THOMPSON was advised that he would be released that evening and moved to the prison reception centre where he was to be out-processed. Mr. THOMPSON expressed concern at the speed of this process and that he would not be able to access personal effects including his mobile telephone and bank cards which, given the time of day (after normal business hours), had been locked away in the prison safe. Mr. THOMPSON appeared distressed at this and expressed suicidal ideation to a prison officer. In response, prison staff sought to reassure Mr. THOMPSON and arrangements were made for out of hours access to his personal effects and his bank cards were returned to him. He was then released from custody at around 19.20 hours, 11th July 2024. Prison staff at this point observed that Mr. THOMPSON appeared to have settled and was content with arrangements made for the return of his remaining personal effects. He had also stated that his son was a protective factor against acting on his earlier expressed suicidal thoughts. Mr. THOMPSON had not been seen by mental health staff as part of his out- processing from prison. Concern was expressed the following day, 12th July 2024 by prison mental health staff that Mr. THOMPSON had been released before the correct discharge procedures relating to his mental health care and treatment could be followed. A referral was then made on the 12th July 2024 to the Community Mental Health Team in Durham where Mr. THOMPSON had his registered address and efforts were made to contact him by telephone. These were unsuccessful. On the 12th July 2024 Mr. THOMPSON presented to the probation office in Durham. The Durham Probation Office was not aware of his release and no appointment had been scheduled. During an exchange with the Duty Probation Officer, Mr. THOMPSON appeared anxious and emotional and reported experiencing suicidal thoughts, although added that he had no plans to act on these. Probation staff contacted the local mental health CRISIS Team, but Mr. THOMPSON refused to engage with them. He was given the CRISIS Team contact details and an appointment made for him to attend the Probation Office on the 19th July 2024. On the 13th July 2024 Mr. THOMPSON travelled by train from Durham to Bury Saint Edmunds to retrieve his mobile telephone from the Bury Saint Edmunds Police Station. He returned to Durham that evening. On the 15th July 2024 Mr THOMPSON bought a rail ticket from Durham to Stowmarket at 10.32 hours. He was observed at Elmswell Railway Station near the ticket machine at 17.15 hours and CCTV at the station then shows his movements around the station until around 17.29 hours. At 17.39 hours he is observed moving from the station platform onto the railway tracks and lying in the path of an oncoming freight train. Police enquiries revealed no suspicious circumstances or third-party involvement in the death. Police found a note from Mr. THOMPSON at his residence in Durham addressed to Family and expressing his final thoughts and wishes. A Postmortem Examination determined Mr. THOMPSON’s medical cause of death as being due to Multiple Injuries. No alcohol or drugs were found to be present in Mr. THOMPSON’s body at the time of his death. 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: Regulation 28 – After Inquest Document Template Updated 30/07/2021 The evidence received at Inquest indicated that inadequate arrangements existed at HMP Norwich to provide for the release of prisoners in receipt of mental health care during out of hours periods. In line with procedures in place at HMP Norwich, Mr. Thompson should have been seen by the mental health team treating him so that appropriate arrangements could be put in place for follow up care and treatment in the community. This did not occur. The mental health team treating Mr. Thompson were only made aware of the fact that he had been released when it was mentioned the following day during a general staff briefing. In addition, Mr. Thompson was not given clear information around when to report to Probation Services, nor were Probation Services advised in a timely manner of Mr. Thompson’s release. As a consequence, when Mr. Thompson presented to Durham Probation Office the day after his release (12th July 2024), staff at the Probation Office in Durham had no knowledge of him or the fact of his release. Neither the failure to properly out-process Mr. Thompson from mental health services at HMP Norwich, nor the failure to inform Probation Services in Durham of Mr. Thompson’s release made a material contribution to his death. However, I am concerned that the evidence heard at Mr. Thompson’s Inquest reveals shortcomings in the internal passage of information at HMP Norwich concerning the release of prisoners in receipt of mental health care and treatment, particularly those who have expressed recent suicidal ideation. In addition, I am concerned as to the adequacy of information passage to the Probation Service relating to the release of prisoners from custody. In another case these failures may give rise to a risk of death. 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 April 3rd, 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 Family of Paul Christoper THOMPSON I have also sent it to Prison and Probation Ombudsman Norfolk and Suffolk NHS Foundation Trust Governor, HMP Norwich Regulation 28 – After Inquest Document Template Updated 30/07/2021 who may find it useful or of interest. 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 Dated: 06/02/2026 Darren STEWART OBE HM Area Coroner for Suffolk 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.
2 a om HM Prison & Probation Service 31 MAR 2026 OFFICIAL HMP/YOI Norwich Knox Road Darren Stewart OBE, HM Area Coroner Mousehold HM Coroner's Court Norwich Beacon House Norfolk White House Road NR1 4LU Ipswich Suffolk IP1 5PB Tel: 01603 708626 Date : 27 March 2026 Dear Sir, Your ref: 01086-2024 | write in response to your Regulation 28 letter which emanates from your inquest into the death of Paul Christopher Thomson. You raised four matters of concern and requested that | respond by April 3 2026. First Concern The evidence received at Inquest indicated that inadequate arrangements existed at HMP Norwich to provide for the release of prisoners in receipt of mental health care during out of hours periods. In line with procedures in place at HMP Norwich, Mr Thompson should have been seen by the mental health team treating him so that appropriate arrangements could be put in place for follow up care and treatment in the community. This did not occur. My Response Mental Health care in HMP Norwich is provided, through an NHS contract, by the Norfolk and Suffolk Foundation Trust. That contract provides cover from 0800 hrs until 1900 hrs on weekdays and on the day of Mr Thompson’s discharge from our prison, a Thursday, NSFT fulfilled their contract. Primary Healthcare again provided by an NHS contract is on site 24 x 7 and is supplied by Healthcare Resourcing Group (HCRG) who should see all prisoners on arrival and on discharge. 1|Page NSFT do not routinely see prisoners on discharge unless they are of the utmost high level of concern. Our Administrators did send an email to the NSFT functional mailbox at 1633 hrs advising that Paul Thompson was cleared for immediate release. As he was not a high level concern NSFT did not attend the discharge unit. The administrator who sent that timely message would not have known that Mr Thompson was talking of suicide to the Custodial Manager in the discharge unit. | am assured by the onsite NSFT manager that if their operative, who was on duty that evening, had been advised of this fact, he would have attended immediately. The contract that the NHS has agreed with NSFT does not require NSFT to attend the discharge unit and thus sign off on a patient such as Paul Thompson. Paul’s discharge procedure was always to be overseen by the duty nurse employed by HCRG. Unfortunately the Custodial Manager in charge of the prisoner's passage to release, inexplicably failed to present Mr Thompson to the nurse and thus he was discharged without any medical clearance. In our local discussions, convened to respond to your Regulation 28 letter, we sought to improve our response to the advantage of those prisoners who were currently on the caseload of NSFT at the point of discharge, whether of high concern or otherwise. A pilot initiative was agreed, and is now in operation, such that a flag on the SystmOne medical record, will be seen by the HCRG discharging nurse. That flag alerts the nurse to the fact that the prisoner being discharged is currently on the caseload of NSFT. The HCRG nurse will immediately call the NSFT duty person to the discharge unit to sign off the patient for release. This of course can only work from 0800 hrs until 1900 hrs. Outside these hours, the role of medically discharging a prisoner falls as ever, to the HCRG who are on hand 24x7, and who do have the contractual responsibility to cover this important process. Second Concern The mental health team treating Mr Thompson were only made aware of the fact that he had been released when it was mentioned the following day during a general staff briefing. My Response Every morning HCRG and when possible in conjunction with NSFT, hold a briefing session to discuss their patients. The NSFT member attending the briefing on 12'" July was not aware that Mr Thompson had been released. However an email timed at 1633 hrs the previous afternoon had been sent to the NSFT functional mailbox. The email is attached at Annex A to this response and shows recipients if opened by , would not have in itself resulted in the practitioners attending the discharge unit. Paul was not at that time considered to be a priority patient requiring any level of attendance from NSFT. However they were advised in timely fashion of the fact that he was to be discharged from the Prison on that day. 2|Page Third Concern Mr Thompson was not given clear information around when to report to Probation Services, nor were Probation Services advised in a timely manner of Mr Thompson's release. Probation office in Durham had no knowledge of him or the fact of his release. My Response | attach at Annex B to this correspondence a copy of the licence given to Mr Thompson as part of his discharge procedure from HMP Norwich. It is dated 11" July 2024 and is signed by Paul Thompson. Your attention is drawn to section 4 of the licence which states .... On release from prison .... you must report without delay to Duty Officer ...... Durham Probation Office Framwell House Framwell Gate Durham DH1 5SU at 10.00 on 12/07/2024 Mr Paul Thompson did exactly that. | attach at Annex C an email sent from HMP Norwich to Durham Probation at 1702 hrs on 11" July 2024. The message clearly tells Durham Probation at Framwell House that Mr Paul Thompson will be reporting to the Duty Officer at 10am on 12" July 2024. They attached the important issue of his DV restraining order and a copy of his signed release licence. | note for your information that | have tasked my in-house Senior Probation Officer to compile a telephone list of active numbers, one for each Probation Area across England and Wales. This will in future days allow my administrators to supplement any email correspondence with a live call alerting our Probation colleagues to the relevant event. In the case of Mr Paul Thompson a Durham Probation number dialled at or shortly before 5pm was not answered. Clearly the incoming e-mail was not processed through to the Duty Officer before Paul arrived at Framwell House at 10am as directed by his discharge licence from HMP Norwich. Fourth Concern However | am concerned that the evidence heard at Mr Thompson’s Inquest reveals shortcomings in the internal passage of information at HMP Norwich concerning the release of prisoners in receipt of mental health care and treatment, particularly those who have expressed recent suicidal ideation. In addition, | am concerned as to the adequacy of information to the Probation Service relating to the release of prisoners from custody. In another case these failures may give rise to a risk of death. My Response Cross referencing with my reply at Concern 1, | hope that your request for urgent improvement regarding the discharge care for patients actively supported by NSFT has been improved from 0800 to 1900 hrs Monday to Friday. 3|Page Our pilot referral and Mental Health In-Reach attendance procedures are now running with the goodwill and understanding of our partners from HCRG and NSFT. After 4 months, we will be in a position to evaluate if the additional support being delivered by NSFT is such that an amendment to contract is thought reasonable. If the extra effort is deliverable without such, it is to be hoped that NSFT will continue to support in that vital manner until contract renewal arises. Thereafter their commercial arm will have to consider their position. It is my consideration that the additional workload will be without significance and | am most grateful for the willingness of NSFT to close this shortfall in the interim period. Outside of the contract hours set for NSFT, the HCRG nurses are fully competent at dealing with all matters of support for men being discharged from HMP Norwich. Such are the nature of our Healthcare Contracts drawn up by NHS England and put out to tender to the private sector. | do believe that we are well covered to support the clientele leaving us, but my Custodial Manager was at fault in this case. On the evening of 11" July, the Operational Manager on duty in the discharge procedure made a significant mistake by not referring the suicidal ideation of Mr Paul Thompson to either NSFT or the Primary Healthcare provider HCRG. This is quite an unthinkable error and cannot be explained away. In fact he totally by-passed Mr Thompson's healthcare discharge. Now it comes to pass that in the interim period between Mr Thompson’s discharge and my writing this letter, that the National Prison Service has been grappling with the long-standing problem of Releases in Error i.e. releasing a prisoner from secure custody when he should still be detained. In tackling that issue, all Prison Discharges are now signed off by two custodial managers and not just one. The dual aspect of checking and rechecking, quite independently of each other, as far as practically possible reduces the likelihood of the discharge going through my final gate without due medical procedures taking place. It is fortunate in assisting me to address your concern and | hope that you can accept my re-assurance on this matter that such human error should not re-occur at HMP Norwich, given the double checks now in vogue. Your final concern here was about our communication with Durham Probation. | trust that | have fully covered that issue in my response to your third concern. However | attach an email sent by my PA apa the same email address used by my staff on 11" July 2024. The response says Delivered: Durham Probation Office Email address. Both of these e-mails to and from Framwell House are attached at Annex D and thankfully confirm that HMP Norwich staff two years ago were using the correct email address for their timely communication with Durham Probation. It is clear that there were some important issues for me to consider following your Regulation 28 letter. | hope that | have addressed them all and that you are content with our positive follow up actions. | believe all the necessary actions to allay your concerns sat within my domain as Governor of HMP Norwich and no issues have been raised by me above establishment level, although | will send a copy of this letter to my Prison Group Director. 4|Page | remain totally open to any follow up you may require or further advice that you may wish to offer. | note the list of persons to whom this letter may be sent and enclose my most sincere condolences to the family of Paul Thompson. Governor HMP Norwich cc: _BCN Prison Group Director Head of HCRG Care Group Specialist Service Manager, Norfolk & Suffolk Foundation Trust 5|Page This e-mail - and any attachment(s) - is intended only for the attention of the addressee(s). Its unauthorised use, disclosure, storage or copying is not permitted. If you are not the intended recipient, please destroy all copies and inform the sender by return e-mail. Internet e-mail is not a secure medium. Any reply to this message could be intercepted and read by someone else. Please bear that in mind when deciding whether to send material in response to this message by e-mail. This e-mail (whether you are the sender or the recipient) may be monitored, recorded and retained by the Ministry of Justice. E-mail monitoring / blocking software may be used, and e-mail content may be read at any time. You have a responsibility to ensure laws are not broken when composing or forwarding e-mails and their contents. From: Sent: uly 2024/16: “ Subject: Immediate Release - Paul Thompson Good evening, The above is an immediate release, he has no discharge grant but will negdartiavelwarrant to Durham via Bury St Edmunds. Regards Offender Management Unit His Majesty’s Prison and Probation Service ae HMP Norwich . Knox Road, HM Prison & NORWICH. Probation Service Norfolk. NR1 4LU. WE ARE PROUD We see the person, uot the pricoucr. *“*OFFICIAL** This e-mail - and any attachment(s) - is intended only for the attention of the addressee(s). Its unauthorised use, disclosure, storage or copying is not permitted. If you are not the intended recipient, please destroy all copies and inform the sender by return e-mail, Internet e-mail is not a secure medium. Any reply to this message could be intercepted and read by someone else. Please bear that in mind when deciding whether to send material in response to this message by e-mail. This e-mail (whether you are the sender or the recipient) may be monitored, recorded and retained by the Ministry of Justice. E-mail monitoring / blocking software may be used, and e-mail content may be read at any time. You have a responsibility to ensure laws are not broken when composing or forwarding e-mails and their contents. LICENCE AND NOTICE OF SUPERVISION Criminal Justice Act 2003 NORWICH (HMP & YOl) 01603 708600 Name: PAUL THOMP 1. Under the provisions of Chapter 6 of the Criminal Justice Act 2003 you are being released on licence followed by a post-sentence Supervision period. The relevant Purposes of each type of supervision are explained in the sections below. 2. Your supervision on licence commences on 11/07/2024 and expires on 21/08/2024 unless this licence is previously revoked, 3. Your post-sentence supervision: period commences on ‘21/08/2024 and expires on 11/07/2025. 4. On release from Prison (including, if applicable, any release from detention under the Immigration Act 1971 during the currency of your licence, whether or not leave has been granted for you to remain in the United Kingdom), unless otherwise directed by: your Supervising officer, you must report without delay to: . Duty Officer As Specified Below Ata location specified by your Supervising officer eit House Fremusest ge. At 10:00 on 12/07/2024 : Licence Period 5. The objectives of the licence period are to (a) protect the Public, (b) prevent re-offending and (c) help you to resettle successfully into the community. You must place yourself under 6. During your licence period you must: 4 Be of good behaviour and not do anything which could undermine the purposes of the licence period: ji. Not commit any offence; iit, Keep in touch with the supervising officer in accordance with any instructions given by the Supervising officer; , LICENCE TYPE = "PSS_AP* Page 1 of 4 Version : §.15 *“OFFICIAL** This e-mail - and any attachment(s) - is intended only for the attention of the addressee(s). Its unauthorised use, disclosure, storage or copying is not permitted. If you are not the intended recipient, please destroy all copies and inform the sender by return e-mail. Internet e-mail is not a secure medium. Any reply to this message could be intercepted and read by someone else. Please bear that in mind when deciding whether to send material in response to this message by e-mail. This e-mail (whether you are the sender or the recipient) may be monitored, recorded and retained by the Ministry of Justice. E-mail monitoring / blocking software may be used, and e-mail content may be tead at any time. You have a responsibility to ensure laws are not broken when composing or forwarding e-mails and their contents. = Sent: 11 July 2024 17:02 Subject: Immediate release - Paul Thompson A1815FD Good evening, The above prisoner has been released this evening after a time served sentence at court. He has an address in Durham and has been given a travel warrant to return there this evening. We have issued a basic licence for him with instructions to attend the Duty Officerat/Durham probation tomorrow morning at 10am. | have attached a copy of his register from court as he has a restraining order for DV, and a copy of his signed licence, which can be amended by yourselves as needed. Kind regards Offender Management Unit His Majesty’s Prison and Probation Service’ we HMP Norwich . Knox Road, HM Prison & NORWICH. Probation Service Cann Norfolk. o NR1 4LU. | WE ARE We vee the pertou, uot the prisoner, **OFFICIAL** This e-mail - and any attachment(s) - is intended only for the attention of the addressee(s). Its unauthorised use, disclosure, storage or copying is not permitted. If you are not the intended recipient, please destroy all copies and inform the sender by return e-mail. Internet e-mail is not a secure medium. Any reply to this message could be intercepted and read by someone else. Please bear that in mind when detiding whether to send material in response to this message by e-mail. This e-mail (whether you are the sender or the recipient) may be monitored, recorded and retained by the Ministry of Justice. E-mail monitoring / blocking software may be used, and e-mail content may be read at any time. You have a responsibility to ensure laws are not broken when composing or forwarding e-mails and their contents. a OCC Sent: 19 March 2026 14:41 To: Durham.FramwellHouse.Reception1 Subject: Durham Probation Office Email Address Tracking: Recipient Delivery Durham.FramwellHouse.Reception1 Delivered: 19/03/2026 14:41 Good afternoon, Please could you confirm that this is the correct email address for Durham Probation Office. Many Thanks Kind Regards Sheryl Sheryl Knights PA to Governor Declan Moore HM Prison and Probation Service x HMP/YOI Norwich ; Woniek HM Prison & We WEARE Norfolk Probation Service PROUD NR1 4LU TOBE Telephone: 01603 708626 Email: sheryl. knights@justice.gov.uk We vec the pervou, uot the prisouct. *“OFFICIAL** This e-mail - and any attachment(s) - is intended only for the attention of the addressee(s). Its unauthorised use, disclosure, storage or copying is not permitted. If you are not the intended recipient, please destroy all copies and inform the sender by return e-mail. Internet e-mail is not a secure medium. Any reply to this message could be intercepted and read by someone else. Please bear that in mind when deciding whether to send material in response to this message by e-mail. This e-mail (whether you are the sender or the recipient) may be monitored, recorded and retained by the Ministry of Justice. E-mail monitoring / blocking software may be used, and e-mail content may be read at any time. You have a + fesponsibility to ensure laws are not broken when composing or forwarding e-mails and their contents Respect) ANNEX D es From: Microsoft Outlook To: Durham.FramwellHouse.Reception1 Sent: 19 March 2026 14:41 Subject: Delivered: Durham Probation Office Email Address Your message has been delivered to the following recipients: Durham.FramwellHouse.Reception1 (Durham.FramwellHouse.Reception1 @justice.gov.uk) Subject: Durham Probation Office Email Address
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