Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0097, written 17 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 | 17 Feb 2026 |
|---|---|
| Reference | 2026-0097 |
| Deceased | Edward Hands |
| Coroner | Bina Patel |
| Coroner area | Bedfordshire and Luton |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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 DEATHS THIS REPORT IS BEING SENT TO: 1 Ministry of Justice (MOJ) 2 HMP Bedford 3 Northamptonshire Healthcare Foundation Trust (NHFT) 1 CORONER I am Bina PATEL, Area Coroner for the coroner area of Bedfordshire and Luton Coroner Service 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 20 February 2024, I commenced an investigation into the death of Edward James HANDS aged 42, who died on the 16 February 2024. The investigation concluded at the end of the inquest on 2 December 2025. The family requested that I refer to the deceased Edward James Hands as Eddie and therefore I will reflect that in this report. The medical cause of death was: 1a Aspiration Pneumonitis 2 Methadone Use The conclusion of the jury inquest was a Narrative Conclusion - After consuming methadone, the major contributing factor in Eddie's death was a lack of follow up care by both healthcare and prison staff. Overall, Eddie's death was contributed to by neglect. On the balance of probabilities, Eddie's death could have been prevented as there was a window of opportunity to intervene. The following factors contributed to the death in a more than minimal way: Insufficient training around the Under the Influence (UTI) protocol; A lack of awareness by prison and healthcare staff in identifying and managing the signs of a UTI case; The availability of staff on the day; High staff turnover, as well as inadequate onboarding of new staff; A lack of cooperation between healthcare and prison management; An omission of discussing the ongoing UTI case during afternoon briefings and/or handovers; An overall lack of accountability in taking ownership of handling the UTI case. Regulation 28 – After Inquest Document Template Updated 30/07/2021 4 CIRCUMSTANCES OF THE DEATH 1) Eddie died on the 16th February 2024 at 1724 in his cell A329, Alpha Wing, HMP Bedford. He died from Aspiration Pneumonitis following consumption of methadone. He was last seen at: 1449, when he was reported snoring in his cell. 2) Access to mental health support services did not contribute to the death. Access to substance misuse support, although broadly beneficial, would not have directly impacted the outcome. 3)There was an Under the Influence Protocol (Bedford Staff Community Notice 265/2023) in place at the time of the death. This protocol was not being used at the time, as evidenced by the number of noted UTI (Under the Influence) incidents (34 in January and 15 in February) and the lack of awareness and recording in the protocol by both prison officers and healthcare staff. Methadone administration at the prison was conducted by two members of staff (healthcare and/or prison staff). However, this was applied inconsistently. 4) Eddie was not prescribed methadone, and it is uncertain how he came to ingest it. On 16th February 2024, Eddie's presenting condition was initially managed in line with the protocol with prison staff raising a Hotel 2 call. Healthcare staff responded to this call. The observations conducted by healthcare staff assessed that he was under the influence. At this point, the UTI protocol should have been started by prison staff and/or healthcare staff, and this did not happen. The lack of follow up visits or checks were a failure in his ongoing care. Thereafter, there was a failure by healthcare staff to carry out a follow up medical assessment or by prison staff as per the protocol. In responding to the 'Code Blue', there was not a full response by healthcare, in that only one of the designated staff members attended. Whilst the evidence does not establish that the following matters probably caused or contributed to Eddie's death, it was admitted that there was a failure of healthcare to use suction equipment to clear the airway at the time he was found unresponsive in his cell and in cardiac arrest with stomach contents in his mouth and throat. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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) The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence. In this instance this confusion resulted in Eddie not being observed; had these checks and monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not recognised and escalated. It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols. Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford Prison. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 14, 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 Eddie’s Family HMP Bedford Northamptonshire Healthcare Foundation Trust Central & Northwest London NHS Foundation Trust I have also sent it to Prisons Probations Ombudsman (PPO) 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. 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: 17 February 2026 Bina PATEL Area Coroner for Bedfordshire and Luton Coroner Service Regulation 28 – After Inquest Document Template Updated 30/07/2021
3 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.
Director General of Operations HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ Bina Patel Area Coroner for Bedfordshire and Luton The Court House Woburn Street Ampthill Bedfordshire MK45 2HX 06 May 2026 Dear Ms Patel, Thank you for your Regulation 28 report of 17 February 2026 following the inquest into the death of Mr Edward James Hands at HMP Bedford on 16 February 2024. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as the Director General of Operations. I know that you will share a copy of this response with Mr Hands’ family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority. You have expressed concerns regarding consistency between HMPPS staff and Northamptonshire Healthcare Foundation Trust (NHFT) Under the Influence (UTI) policies and protocols. Following the conclusion of the inquest HMP Bedford and NHFT carried out a joint review of the UTI policies and protocols in place. This review resulted in the removal of any previous conflicting guidance and implementation of a single UTI protocol with standardisation of responsibilities, including observation requirements, escalation routes, and handover expectations. This protocol has been agreed by both parties and is to be followed by both operational and healthcare staff at HMP Bedford. The updated protocol has been issued to all prison and healthcare staff through structured briefings, written notices, daily meeting updates, and daily checks. Furthermore, the following additional actions have been carried out to reinforce the updated protocol: 6 • Staff have been given guidance on recognising signs of being UTI , initiating the protocol, completing observations, and ensuring follow up checks are undertaken. • A newly appointed substance misuse lead carries out daily assurance and visits all suspected UTI cases, ensuring consistency between operational and healthcare colleagues and consistent adherence to the UTI protocol. • Every UTI related incident is now logged and tracked to support monitoring and learning. • Assurance of documentation and observations is completed to ensure compliance of timescales and escalation procedures. Where this identifies areas requiring improvement a record is made and the issue escalated to both prison and healthcare senior leaders to be addressed as appropriate. • Learning is shared across teams and discussed in the monthly Healthcare Partnership Board, attended by senior leaders from both the prison and healthcare. This ensures that all parties have the opportunity to raise any issues and these can be addressed and monitored. I hope the measures outlined above taken by HMP Bedford, in partnership with NHFT, provide you with reassurance that learning and appropriate action has been taken from the circumstances of Mr Hands’ death. Yours sincerely Director General Operations 7
HMP BEDFORD LOCAL UNDER THE INFLUENCE PROTOCOL
We have seen a worrying increase in prisoners that are found to be under the influence (UTI) of
unknown substances recently. It is important that we all know the correct processes to follow, to
keep our prisoners, colleagues and ourselves, safe. Upon identifying a prisoner suspected to be UTI,
you should:
- Activate your Body Worn Video Camera immediately and notify your colleagues for
assistance
- Call Hotel 2 and or Hotel 1 to attend to the incident.
- The prisoner should be taken back to their cell if safe to do so
-
If presenting with severe symptoms, consider if a Code Blue needs to be called and continue
with first aid response.
Following assessment of the prisoner from Hotel 1/2, if confirmed as suspected of being UTI:
• Healthcare will advise you on the frequency, and for how long the welfare observations on
the prisoner should occur for. This should be documented in the observation book along with
the follow-on observations.
•
If a prisoner appears to recover quickly, you should continue the observations, and the
prisoner should remain as ‘resting in cell’ for this period. Staff must ensure that meals are
taken to the prisoner in the cell during this time.
• When completing observations, you must ensure that the prisoner is alert, responds
appropriately to your voice, and if they have deteriorated, assess the need to call Hotel 1/2
or Code Blue.
•
If the prisoner appears to recover and wishes to attend their visit/activity or appointment,
they should be reassessed to determine if they are fit to attend. This can be done by
Hotel1/2, or a defensible decision should be made by Victor 1.
• The prisoner should be placed on report, under the charge “Disobeys or fails to comply with
any rule or regulation applying to him” Prison Rule 51, paragraph 23, and basic for a 28-day
period, with a 14-day review where this can be lessened, if there is engagement with
supporting change. Those on Basic should be managed accordingly and every effort should
be made to move the prisoner into a cell with another basic prisoner to allow for removal of
TV.
• The UTI form needs to be completed. On the UTI form, the First on Scene Officer should
document why they believe the prisoner to be UTI and there is a section for Hotel 1/2 to
complete. This paperwork needs to be taken to the CASU as evidence ready for the
adjudication.
• A cell search needs to be conducted, with any drug paraphernalia or unauthorized articles
removed as evidence and the prisoner should be placed on report for them. A body scan
should not be routine however it is to be used on suspicion or related intelligence, and
approval must be sought from V1.
• Oscar 1 should be informed, and an incident report needs to be completed, along with the
completion of an IR and NOMIS case note.
• All prisoners that have been UTI should be added to the priority key work list and discussed
at the following SIM.
11
Additional information:
Below are some common signs to look out for if you suspect a prisoner is UTI which you can also
include on the UTI form description is relevant. Please be mindful that this list is not exhaustive due
to the ever-changing illicit substances entering the prison community.
Physical signs of being under the influence:
Confusion/disorientation
Aggression
Sweating
Red Eyes & Dilated or Constricted Pupils
Anxiety or Paranoia
Poor coordination
Sudden change in mood
Vomiting
•
•
•
•
•
•
•
•
Signs of Overdose:
•
•
•
•
•
•
•
•
•
•
•
Breathing slowly or very shallow
Unconsciousness
Lips/nails blue
Chest pain
Nausea
Stroke
Seizures
Gurgling or snoring sounds
Tremors
Hot/clammy skin
Vomiting
Other signs to look out for:
•
•
•
•
•
•
•
•
•
•
•
•
•
Changes in appetite
Needle marks
Loss of interest in hygiene or grooming habits
Unusual smells
Finding drug paraphernalia
Changes in sleep patterns
Noticeably different energy levels
Drastic personality change
Being dishonest or sneaky, hiding things, or needing increased privacy
Debt
Loss of memory
New peer groups
Missing work with no legitimate excuse
12
CHIEF EXECUTIVE AND CHAIR’S OFFICE Berrywood Hospital Berrywood Drive NORTHAMPTON NN5 6UD 10 April 2026 FAO Ms Bina Patel Area Coroner for Bedfordshire and Luton Dear Ms Patel RE: Regulation 28 Report Concerning Edward James Hands We write in response to your Prevention of Future Deaths Regulation 28 (‘Report’) dated 17 February 2026 concerning the death of Edward James Hands on 16 February 2024. Before responding to the matters of concern you have included within your Report, I would like to express my condolences to Mr Hand’s family and loved ones. From your Report, we understand that you have concerns about the arrangements in place within Bedford Prison to manage those suspected to be ‘under the influence of illicit substances’. Specifically, you are concerned that the healthcare and prison teams are working to difference policies/procedures; that there is a lack of awareness of roles, responsibilities, and processes that should be followed in such circumstances; and that any Trust-wide policy/procedures we have in place should be clear on what happens when individual institutions have their own local protocols. You have asked The Trust to either provide details of action taken, or proposed to be taken, or to explain why no action is proposed. Please find below our response to your concerns detailing the actions being taken. Cont’d/… Trust Headquarters: St. Mary’s Hospital, London Road, Kettering, NN15 7PW 8 Our common protocol for managing those suspected to be Under the Influence We have worked with the Prison Governor and Head of Safety to agree and implement a common, local protocol for managing those suspected to be under the influence of illicit substances (UTI) at HMP Bedford. I have enclosed a copy of the protocol with this letter for your information. The protocol clearly articulates the roles, responsibilities, and expectations of both healthcare and prison staff in the identification, assessment, and management of those suspected to be UTI. The protocol makes it clear when prison staff should escalate to healthcare staff. It states that healthcare staff are responsible for taking the lead on UTI cases in which medical intervention is required. We have included a flowchart as an appendix to the UTI protocol to ensure this is clearly understood by both healthcare and prison service team members. Ensuring prison and healthcare staff are aware of their roles and responsibilities The healthcare and prison service leadership teams circulated the UTI protocol and an amended UTI recording log to staff late last year. Mandatory training for healthcare staff on UTI detection and management is being facilitated by the Trust’s Resuscitation Lead and is part of our induction programme. An ‘Airways Champion’ has also been identified. The Airways Champion supports our leadership team in maintaining competence in airway management and suction machine use. They will also help deliver future UTI simulation training sessions. A new monthly meeting between prison and healthcare leaders We have established a new, monthly meeting between the Head of Healthcare and Prison Governor focused on operational matters of healthcare and prison service integration. This new meeting complements our existing Partnership Delivery Board, which serves as the primary mechanism for shared tactical oversight and decision- making on matters within the agreed terms of reference. These strengthened arrangements will help us to maintain aligned and effective working relationships between healthcare and prison service teams, learn lessons from any issues that may arise, and capitalise on opportunities for innovation and improvement. Cont’d/… Trust Headquarters: St. Mary’s Hospital, London Road, Kettering, NN15 7PW 9 I hope the content of this letter fully addresses the concerns you raised in your Report and provides assurance on the steps we have taken. Please contact me if you have any questions about this letter or require further information. Yours sincerely Chief Executive NORTHAMPTONSHIRE HEALTHCARE NHS FOUNDATION TRUST Enc: HMP Bedford Local Under the Influence Protocol Cc: , Chief Medical Officer , Group Chief Nurse , Chief Operating Officer , Manging Director and Deputy Chief Executive Trust Headquarters: St. Mary’s Hospital, London Road, Kettering, NN15 7PW 10
See every Prevention of Future Deaths report matching State Custody related deaths, 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.