Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0080, written 10 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 | 10 Feb 2026 |
|---|---|
| Reference | 2026-0080 |
| Deceased | David Thompson |
| Coroner | Alison Longhorn |
| Coroner area | Devon, Plymouth & Torbay |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. , Chief Constable, Devon & Cornwall Police. 1 CORONER I am Alison Longhorn, Area Coroner for the coroner area of the County of Devon, Plymouth & Torbay. 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 A coronial investigation was commenced on 9th March 2023 into the death of David John Thompson, aged 46. The investigation concluded at the end of the inquest on 3rd February 2026. The conclusion of the inquest was suicide, and the medical cause of death was recorded as 1a) hanging. 4 CIRCUMSTANCES OF THE DEATH On 6th March 2023, David Thompson went missing from his home address. He had a history of low mood, had expressed thoughts of suicide previously, and had been experiencing a number of challenging life events in the weeks before. His partner reported him missing to the police and he was graded as a ‘medium risk’ missing person. He was located the following morning, 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. – (1) The inquest heard that when Mr. Thompson’s partner reported him missing to the police, she was repeatedly asked (by both the 999 call handler and the attending police officers) whether he had demonstrated any ‘suicidal ideation’. It was clear that she did not fully understand what that meant, and as a result information which would have been relevant to the consideration of the level of risk presented by Mr. Thompson going missing was not recorded by the police. (2) Furthermore, I heard evidence that the term ‘suicidal ideation’ was still being widely used by the constabulary when asking questions of members of the public who were reporting missing persons, and I am concerned that a member of the public may not understand what is being asked of them and may not therefore respond appropriately. (3) During the course of the inquest I heard evidence from 5 police officers and 2 members of police staff. When asked what their understanding of the term ‘suicidal ideation’ was, their answers were vague and inconsistent. There therefore appears to be a lack of understanding by those employed by the police as to what the term means, creating a danger that the risk posed by a missing person is not fully appreciated by staff responding to a missing person report. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths, and I believe you and 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 8th April 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: - - - - (via her legal representative) (via their legal representative) 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 10.02.26 Alison Longhorn
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.
Assistant Chief Constable Police Headquarters, Middlemoor, Exeter, Devon, EX2 7HQ BY EMAIL: - Subject: Death of David John Thompson (ref: 15607320) Dear HM Coroner PREVENTION OF FUTURE DEATH RESPONSE FOLLOWING THE INQUEST INTO THE DEATH OF DAVID THOMPSON MATTERS OF CONCERN: USE AND UNDERSTANDING OF THE TERM “SUICIDAL IDEATION” I am writing in response to the Regulation 28 report into the prevention of future deaths notice, that was issued on 10 February 2026 and sent to the Chief Constable of Devon & Cornwall Police, James Vaughan. The Chief Constable has asked me to respond to this notice, as the matters of concern raised therein fall within my area of policing responsibility. Please therefore treat this correspondence as the Chief Constable’s formal response to the Regulation 28 Notice. The Chief Constable and myself want to take this opportunity to express our condolences to Mr Thompson’s family and friends. We are sincerely very sorry for their loss. Additionally, the Chief Constable and I also want to thank you for bringing the matters of concern set out in the Regulation 28 Notice to our attention. We welcome opportunities to give serious consideration to any matters of concern such as this with a view to improving the service that we provide the public, and to assist you and your coronial colleagues in your investigations. Devon & Cornwall Constabulary acknowledges the concerns raised regarding the use and understanding of the term ‘suicidal ideation’ within operational decision- making and communications with members of the public. As a Force, we will continue to deliver refresher training to Control Room Staff to further strengthen their understanding of suicidality, associated risks, and the dynamic and fluctuating nature of such incidents. Guidance issued in 2024 clarified that the term ‘suicidal ideation’ refers to thoughts of suicide (with reference to publications within the Lancet, and commentary provided in open-source by the Samaritans within which ‘ideation’ relates primarily to ‘thinking about suicide or could be making a plan to take their own life. This can range from a passing thought to a detailed plan’). This clarification has been further reinforced and incorporated into training and operational guidance that is being issued and delivered throughout 2026 – with specific emphasis on the wide variety of incidents and risks that the term encompasses. Training for Control Room supervisors and staff continue as part of ongoing refresher programmes. With greater focus, these sessions explore the definitions, meanings, and associated risks linked to suicidality. Staff are reminded that language used when assessing and communicating risks must remain clear, concise, and understood within its basic meaning. Whilst ‘suicidal ideation’ may be considered a clinical term in some contexts, the Force recognises that in emergency situations and when communicating with members of the public, it is often more appropriate to use plain language that is not prescribed or confined to a single definition. Accordingly, operational practice encourages the use of straightforward terminology such as ‘thoughts or feelings about suicide’ when discussing potential suicide risk. Officers and staff are also reminded that suicide risk can fluctuate rapidly, particularly where factors such as intoxication, significant trigger events, or access to means change (this list is not exhaustive). The Force recognises that over-reliance on rigid definitions, structured terminology, or scripted questions, may create false reassurance and could potentially increase risks. For this reason, operational messaging within Control Room refresher training and frontline operational guides prioritises the use of clear, accessible language and encourages open questioning to fully understand the circumstances being reported and avoid ‘language-driven information loss’. Control Room teams are therefore encouraged to use plain language and to ask broader exploratory questions, rather than relying on a single question relating specifically to ‘ideation’, when assessing risk. Consequently, the following actions have been taken: - 1. Continued emphasis on the use of plain language throughout Control Room refresher training which will continue to be delivered throughout 2026. 2. Formal clarification within 2024 guidance that the term ‘suicidal ideation’ simply means ‘thoughts or feelings of suicide’ – this continued to be reinforced. 3. Reinforcement of the above approach to frontline officers and staff through the introduction of operational guidance (Op Guides) relating to incidents involving Article 2 risks and suicidality. 4. Recognition that ‘suicidal ideation’ is not a nationally standardised policing term; therefore, communications and training have been undertaken to ensure staff understand the broad spectrum of risk that the term may encompass. We have also undertaken some work with other Forces and have become aware of a ‘Ovenstone criteria’ (A criteria formed in 1973 by Dr. Irene Ovenstone) Whilst predominantly an investigative method to assist in determining whether a death was likely to be suicide, it is also useful for determining suicidal risk and provides some evidence of suspected pre-suicidal criteria and we are actively exploring this use. Devon & Cornwall Constabulary remains committed to ensuring that officers and staff are equipped with the knowledge, language, and operational guidance necessary to identify and respond appropriately to individuals presenting with suicide risk. Yours sincerely, Assistant Chief Constable 29th March 2026
See every Prevention of Future Deaths report matching Suicide (from 2015), and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.