Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2026-0111, written 16 Sep 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Sep 2025 |
|---|---|
| Reference | 2026-0111 |
| Deceased | Hilary Chapman |
| Coroner | Simon Connolly |
| Coroner area | County Durham and Darlington |
| Category | Mental Health related deaths |
| 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 DEATHS
THIS REPORT IS BEING SENT TO:
1 TEWV
1
CORONER
I am Simon CONNOLLY, Assistant Coroner for the coroner area of County Durham and
Darlington
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 12/03/2025 11:21an investigation was commenced into the death of Hilary Jane
CHAPMAN 18/02/1976. The investigation concluded at the end of the inquest on
05/02/2026 00:00. The conclusion of the inquest was that Hilary Jane Chapman died on
11th March 2025 8:45am at St. Cuthbert’s Hospice, County Durham.
Hilary suffered from recurrent depressive disorder. She had historically attempted suicide
and been detained under section 2 and 3 under the Mental Health Act. Hilary was under
section 3 during the events leading up to the cardiac arrest.
Based on evidence heard, Hilary’s mental health began to decline in September 2024.
Hilary was detained under section 2 of the mental health act on 25th November 2024 at
West Park Hospital following reports of self-neglect. She was later transferred to Lanchester
Road Hospital, on 17th December 2024, onto Tunstall ward. She was detained under
section 3 on 20th December 2024.
By January 2025, Hilary was self-medicating, and her RC believed she was showing
improvement. Hilary was prescribed escorted and accompanied leave which she would take
with her sister or friend.
Leave was suspended at the end of January due to changes in presentation.
On the 18th February 2025, an MDT meeting took place which was attended by Hilary and
her sister and other professionals involved in Hilary’s care. The prospect of leave was
discussed, however the dates of leave were not established in this meeting. After this
meeting concluded, the RC spoke to the ward staff and prescribed section 17 leave for
daytime unescorted leave from 18th February 2025 at 9am until 10th March 2025 at 9am.
He also included overnight unescorted leave the weekend of 22nd February 2025 at 5pm
until 24th February 2025 at 12 noon. The dates of this weekend leave were not discussed in
the MDT meeting. RC completed Section 17 leave form and this was signed by himself and
Hilary. However, Hilary’s signature was not dated. The jury also notes that this form was
not completed as the form instructs that it is ‘given to relevant people including the patient,
accompanying person, carer…’. This form was not shared with Hilary’s sister who was
identified as Hilary’s carer.
From the 18th February 2025 to the 21st February 2025, Hilary utilised daytime unescorted
leave. There was no attempt from the ward to contact Hilary during this leave, despite
being stipulated by the section 17 leave form. However, she returned on time each day.
Regulation 28 – After Inquest
Document Template Updated 30/07/2021
On 22nd February 2025, Hilary asked to utilise section 17 unescorted overnight leave which
was approved by the nurse in charge. The nurse in charge asked Hilary what she was going
to do and Hilary said she was going to see her sister. She did not have any concerns for
Hilary’s wellbeing. Jury notes that Hilary was allowed to leave before the stipulated time of
5pm on the section 17 leave form for overnight leave.
Lanchester Road Hospital CCTV and CCTV ANPR show Hilary’s following movements. On the
22nd February 2025, Hilary left Lanchester Road at 12:32 after collecting weekend
medication from the main reception. She then left Lanchester Road and got into her car.
Her car was seen travelling through Durham towards home address noted again to be
travelling back through Durham towards Crook. At 13:10, she parked behind the surgery in
Crook and walked through to Hope Street. She is seen entering the pharmacy which she
had keys to. This pharmacy was Hilary’s previous place of work where she was co-owner /
director. Hillary came out of the pharmacy 6 minutes later with something unidentifiable in
her hand. Her car then drives through Durham city centre at 13:30 back towards home
address. CCTV next identifies her car at 17:30 in Durham city centre. The vehicle is noted
by Lanchester Road CCTV entering the carpark to the hospital at 17:39, parking up briefly
near the main entrance before moving the vehicle out of view from CCTV. There is no
further CCTV images of this vehicle or Hilary.
Hilary’s phone records show that she received calls from a no-caller-ID at 20:12 on the
22nd February 2025. She received further calls on the 23rd February 2025 at 15:54 and
18:52 and on the 24th February 2025 at 10:35. These calls were not answered by Hilary.
The ward attempted to contact Hilary over the weekend, but no contact was made. Nurses
on duty did not believe that Hilary’s risk had increased on the Saturday. Nurse in charge
sought advice of a senior nurse after lack of contact on the Sunday. No action was taken
due to Hilary not meeting criteria as a missing patient. An MDT meeting of hospital staff
took place on the morning of the 24th February 2024 and still no actions were taken.
At 12:00 on the 24th February 2025, Hilary did not return. This triggered the nurses to act
on missing persons procedure. Phone records demonstrate a call from no-caller-ID at 12:19
made to Hilary’s phone. This was not connected. Nurse in charge called Hilary’s sister to
inform her that Hilary had not returned. Sister made them aware that she was not in the
Durham area and was on a family holiday in Norfolk and had not spoken to Hilary since
Friday 21st February 2025. Her sister said she was unaware that Hilary had been
prescribed this weekend leave. Nurse in charge contacted the police and reported Hilary
missing at 12:30.
Hilary’s sister contacted friends in the area to go to Hilary’s home address. They reported
Hilary was not there and neither was her car. Hilary’s sister rang the ward back and asked
them to check the car park. The nurse in charge told the jury that a search of the grounds
took place however there was no evidence to support this.
Police officer attended Hilary’s home address at 15:00 then went to Lanchester Road
Hospital and searched Hilary’s room on Tunstall Ward at 16:48. Police noted that Hilary had
not left many of her things behind. As the police officer was leaving Lanchester Road
Hospital, they identified Hilary’s car parked in an area of the car park not covered by CCTV
at 17:20.
Hilary was found in the back footwell of her car behind the passenger seat with a blanket
over her. Hilary was removed from the car. Nurse in charge was aware that paramedics
were on site and were called to the scene. Paramedics arrived and they determined she had
experienced cardiac arrest. CPR was administered for 17 minutes until spontaneous
circulation was restored. Paramedics also administered adrenaline and a glucose stabiliser.
Paramedics noted that Hilary had low body temp (30.4) and low blood sugar (2.2mm/ol).
An undated note was found under the front driver seat which suggested an attempted
suicide.
Regulation 28 – After Inquest
Document Template Updated 30/07/2021
Hilary was taken by ambulance to University Hospital North Durham. Hilary was admitted
and a blood sample and urine sample were taken due to suspected overdose. The hospital
tested for drugs commonly used in overdoses and the drugs that Hilary was prescribed or
had historically overdosed on. No tested drugs were found.
Intensive care consultant asked for bloods to be stored but none were available for further
tests. Police failed to request for bloods to be retained.
The ITU consultant noted Hilary to be in a deeply unconscious state with a GCS of 5.
On 28th February Hilary was taken for a second CT scan which confirmed she had a hypoxic
brain injury.
Hilary was transferred to a palliative care team and further transferred to St Cuthbert’s
Hospice on 5th March 2025. Hilary received palliative care and sadly passed away on 11th
March at 8:45am. Brother-in-law confirmed Hilary’s identity.
Police investigation ruled out any third party involvement in Hilary’s death. Evidence
demonstrated that Hilary took her own life. Applying the balance of probabilities, evidence
suggests that it is probable that Hilary intended to take her own life..
4
CIRCUMSTANCES OF THE DEATH
. Hilary had then been on unsupervised
was aware of. Hilary went on unsupervised leave and
Hilary was under a section 3 at Lanchester Road Hospital for her depression. Hilary had
been out for supervised leave with her sister
leave which
was not
made aware of this. Hilary did not return on the expected time and a search was started.
Hilary was found in her own car in the car park at Lanchester Road on 24/2/25. Hilary was
found with a suicide note and mixed overdose was presumed cause of cardiac arrest. Hilary
was not breathing and did not have a pulse and CPR was started. Hilary had return of
circulation from CPR and was transferred to CDDFT ITU where she received care to stabilise
her cardiac output. Hilary had a CT head 28/2/25 which showed extensive Hypoxic brain
damage and a Best interest decision was done with her sister who felt Hilary would wish for
palliative care now. Palliative Care team at CDDFT were involved with discussions around
this. Hilary was referred to St Cuthbert's Hospice for end of life care and admitted to the
Hospice on 05/03/2025. Hilary was kept comfortable with a syringe driver at the Hospice to
manage her secretions. Hilary died on 11/3/25 at 8.45am
All history from sister
l and CDDFT Referral letters.
Information From Police
Hilary worked as a Pharmacy Technician at her family pharmacy’s in Crook on Hope Street.
On 22/02/2025 when the pharmacies are closed, chapman leaves LRH on her leave. She
appears to drive home, then drive through Durham and towards Crook. CCTV shows her
parking and walking to one the pharmacy on Hope Street. She had access via keys and
knew the alarm code. She is inside (no cctv inside or stocktakes to establish what was
taken) for around 6 ins and leaves. She returns home, and travels back in the direction of
LRH around 1740hrs on 22/02. She is not seen or heard from again until 24/02 at 1710hrs
when found by police slumped in her car in LRH car park away from the building. It appears
she may have attended the pharmacy to obtain medication to overdose. Her sister and
family were in Norfolk that wkd.
Police Referral
Hilary CHAPMAN was a section 3 patient at Lanchester Road Hospital, and from 18/02/2025
she was allowed unescorted leave under section 17. She has left L.R.H. on 22/02/2025 and
was due to return on 24/02/2025. On her failure to return, L.R.H. has alerted Police and
her family who have not heard from her. Chapman was found in the rear footwell of her car
unconscious following possible overdose. Ambulance attended and CPR was given.
Chapman was taken to University Hospital North Durham. A note to her sister
was
Regulation 28 – After Inquest
Document Template Updated 30/07/2021
found in her vehicle relating to Hilary's wishes to end her own life. A/DS 2159 Denham will
submit an MG11 report in due course as he has dealt with the investigation. It is being
deemed as non suspicious and a suicide with no third party involvement. DCI
has been
spoken to by A/DS Denham and it is not believed a Home Office Post mortem is required as
Hilary was on leave from LRH.
TEWV:
S.3 MHA was discharged on 6 March due to being on palliate care.
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)
Tees, Esk and Wear Valley NHS Foundation Trust ('the Trust") gave evidence of policy
changes to the way in which section 17 leave was prescribed and also how families were
informed and updated of such prescribed leave. The Trust explained the new processes as
involving the discussion and agreement of a "Leave Plan" based on the completion of a
"Leave Discussion Form" which documents the discussions which have taken place and the
terms and conditions of any prescribe leave, with the "Leave Plan" being shared with any
person involved in the patient's supervision whilst on leave.
Whilst improvements by the Trust to the way in which section 17 leave is discussed,
prescribed and shared are acknowledged and welcomed and whilst I acknowledge what I
was told about staff training having been undertaken in respect of the new processes, I was
concerned that the overarching and updated section 17 leave policy makes no reference to
these new processes. I was told that a review of the policy was contemplated although not
likely before September 2026. I am concerned at this evidenced gap in Trust policy.
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 05, 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.
COPIES and PUBLICATION
8
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons
I have also sent it to
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
Regulation 28 – After Inquest
Document Template Updated 30/07/2021
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: 08/02/2026
Simon CONNOLLY
Assistant Coroner for
County Durham and Darlington
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.
Office of the Chief Executive West Park Hospital Edward Pease Way Darlington Co Durham DL2 2TS Simon Connolly Assistant Coroner for County Durham and Darlington 1 April 2026 Dear Mr Connolly, The purpose of this letter is to respond to the Report to Prevent Future Deaths (PFD), served on the Trust on the 8 February 2026, regarding the Trust's Mental Health Act Section17 Leave Policy in line with the findings of the hearing in February 2026 into the death of Hilary Chapman Just a short note at this stage to on 11 March 2025. acknowledge receipt of your letter dated XXXX 2017 bringing On receipt of the PFD, the Trust's Chief Nurse and Medical Director commissioned a working to my attention concerns raised group consisting of; the Trust's Care Group Director of Nursing, Deputy Care Group Director by your above named constituent of Nursing, Associate Medical Director, Associate Director of Nursing for Urgent Care and the in respect of XXXXXXX Deputy Head of Mental Health Legislation, to review the current Section17 Leave Policy in relation to the specific concerns that were raised. A full review of the Section17 Leave Policy I have asked for an investigation is planned for early June 2026 which will involve all stakeholders, including those with lived to be carried out into the experience of receiving services and of caring for those who receive services. concerns raised by XXXXX following which I will send a The working group met a number of times and have agreed that the following immediate policy detailed reply to you. changes were required: i) ii) iii) iv) With kind regards For clinicians to have clear direction regarding the expected processes for prescribing and arranging Section 17 leave Yours sincerely For consideration of contingencies to be incorporated into Section 17 leave planning Wherever possible and practicable, to increase family involvement in leave planning. Uniformity throughout the Trust for risk assessing when planning Section 17 leave and the recording of this within the patient electronic care record. In order to address these identified changes, as of April 3rd 2026 we have amended the Section Colin Martin 17 policy to direct staff to PIPA (Purposeful In - Patient Admission) procedures and standard Chief Executive processes. This directs adult acute admission ward staff to the relevant documentation Date required to ensure the above. This includes the, a) Leave risk discussion form. b) Standard operating procedures for the completion of the leave plan in the electronic care record. The following immediate, stipulations within the Section 17 leave policy have also been made: i) ii) iii) That family, friends or carers involved in someone's care are to be kept up to date with significant changes to the persons leave arrangements. That family, friends or carers involved in someone's care receive a copy of the leave plan, in line with the wishes of the person going on leave. The section 17 leave form is not the leave plan and does not need to be shared with the family, friends of carers. For any agreed contingencies, should Section 17 leave not go according to the agreed plan to be shared with all ward staff to inform them about agreed next steps. We would like to assure H.M.C. that the improvements he noted at inquest and in the Prevention of Future deaths report regarding how we discuss, prescribe, and share plans about leave have been maintained with recent audit results showing that positive progress has been sustained. We continue to have monthly oversight of our compliance with the expected safety planning for section 17 leave via our Quality Assurance schedule. We hope that the above demonstrates the changes that we have made to improve our policy to ensure robust safety planning for Section 17 leave and that we will continue to monitor this closely to ensure that any changes are understood and embedded. Yours Sincerely Chief Executive
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