Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0128, written 5 Mar 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Mar 2026 |
|---|---|
| Reference | 2026-0128 |
| Deceased | Joanna Hillard |
| Coroner | Samantha Marsh |
| Coroner area | Somerset |
| 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 (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. Secretary of State for Health and Social Care,
1
CORONER
I am Samantha Marsh senior coroner, for the coroner area of Somerset.
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 the 26th February 2021, my predecessor, Mr Tony Williams, commenced an
investigation into the death of Joanna Hillard. The investigation concluded at the end
of the inquest, heard by me, on the 26th February 2026. The conclusion of the inquest
was
Box 3: Joanna HILLARD, aged 64, was discovered
home address at around 09:18hrs on the Twenty-Fifth of February 2021. She was last
seen alive at 22:30hrs the evening before and so it is not known exactly when she
at her
Despite CPR she could not be revived and was pronounced
deceased by the attending paramedic. Joanna's specific motivation to act as she did
is not fully clear on the evidence available, but on the balance of probabilities derived
from her low mood due to a coercive and controlling domestic relationship and her
social and living circumstances, and this has more than minimally contributed to her
death.
Box 4: Suicide contributed to by coercive and controlling behaviour
4
CIRCUMSTANCES OF THE DEATH
1
behaviour was caused by either his Parkinsons
The inquest explored whether
or the Pramipexole medication he was prescribed. His Parkinsons Nurse, after
liaising with his Consultant, told friends and professionals that this was unlikely
because
commonly seen with much higher doses than
the Inquest was that
cause his behaviour but on the balance of probabilities it exacerbated underlying
personality traits.
was on such a low dose and such behavioural changes are more
condition and/or properly prescribed medication did not
was on. One of the findings at
From the September of 2019
embarrass, belittle, intimidate and control Jo, and isolate her from her friend and
family. The inquest heard examples of this:
embarked on a relentless campaign to
(i)
(ii)
(iii)
(iv)
(v)
(vi)
forced her to relinquish her carers
Her finances were controlled (
allowance by frightening her into thinking she was committing fraud. This
meant that she had no access to independent financial means).
He made her recount in mortifying detail
and neighbours her [his perception of her] sexual inadequacies
Witnesses explained that Jo was a private and dignified person and she
would have found this experience utterly humiliating and mortifying.
, friends, family
had found a Filippo bride online. He
but insisted
that they remain living together in the home so that Jo could continue to
care for him once his Filipino bride and her relative had obtained a visa;
with the four of them living in the house together.
He tried to bully Jo into signing her
him, which would have left her homeless and with nothing.
Jo engaged a solicitor to help her
and once
meaning that she had no independent and factually correct advice about
her position and her rights; it was only what
was telling her.
She had to contact her children, friends and family in secret as her
conversations were monitored, or
background telling Jo what she was to say.
found out about this, he made her end the retainer,
could be heard in the
property matters
home over to
The coercion and control continued even when they were not physically together. In
February 2020 Jo was taken by family to Scotland. Whilst there Phillip phoned her
relentlessly for hours throughout the day and night until she went home. In March
2020
still controlled Jo’s movements, what she did and who she spoke to etc.
went to the Philippines to meet his internet-bride and during his absence
remained living together. Whilst administrative
processes were in place for his internet-bride to be granted a visa, there were no firm
plans or date when she was expected to be in the country and/or living with them.
Evidence from family was that the situation had settled a bit by November 2020.
On the 25th February 2021, Jo was discovered
home.
workshop/garage attached to the
in the
left the UK after Jo’s death to live in the Philippines, where it is understood he
still resides, and so there has been no investigation, prosecution or conviction under
Section 76 of the Serious Crime Act 2015. During her lifetime Jo did not/would not
support a prosecution.
I was satisfied that Jo was not happy in her living situation but did not feel able to
leave because (i) she had been brainwashed (to quote the family’s phrase) by
into believing all of this was her fault and so she felt guilty and that she ‘owed him’
and it was therefore her duty to say and (ii) she wanted to protect
his behaviour which he also exhibited towards them when he was unable to control Jo
to the extent and degree that he wanted. He would use his Parkinsons Disease as a
weapon and would continually play the consummate victim (even though he was
anything but).
from
2
The Court heard from a variety of professionals who were either directly involved with
Jo, or involved ‘behind the scenes’ trying to protect and safeguard her.
The IDVA (Independent Domestic Violence Advocate) told the Court that this was the
worst example of coercion and control that she had seen in her 16 years of
experience. Multiple professionals from domestic abuse and safeguarding
units/organisations and departments were involved with Jo. All agreed that whenever
she spoke it was a regurgitation of
needed, how he viewed things; she had lost the ability to identify and say “I”
want/need/think/feel. She was stuck in a relentless cycle of self-blame; enforced on
her by
thoughts and decision making process even when he wasn’t in the room with her (and
professionals, quite appropriately, insisted on seeing Jo on her own. They also had to
see her on her own due to covid and the requirement for social distances). The
physical separation did not make a difference; the mental and emotional control was
still there.
. Her family described her as being “brainwashed”.
narrative; what he wanted, what he
controlled her
All professionals trying to support Jo agreed that what they wanted for her, and what
, but
she needed to be able to recover, was to leave
she would not do this due to the coercion and control. All professionals were equally
‘professionally frustrated’ by their lack of power to take decisions in her best interests
to keep her safe. Jo was assessed, under current legislation (the Mental Capacity Act
2005) as having capacity to make decisions to remain living with
, even if those
decisions were regarded by others as unwise.
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. –
The provisions of the Mental Capacity Act 2005 (which Jo was assessed under) , pre-
date the Serious Crime Act 2015, particular Section 76 which relates to the offence of
controlling and coercive behaviour.
The Mental Capacity Act 2005 aims to ensure that people with social care needs who
have an impairment of their brain or mind are supported to make their own decisions,
wherever possible, on a background of least-restrictive options to curtail someone’s
liberty and freedom of action. People should be assumed to have mental capacity
unless it can be demonstrated otherwise.
The Mental Capacity Act only applies if at the material time he/she is unable to make
a decision for himself/herself in relation to the matter because of an impairment of, or
disturbance in the functioning of, the mind or brain” (Section 2(1)) MCA 2005).
I am concerned that there is a lack of understanding of the effects of controlling and
coercive behaviour on a person’s ability to make a decision in their best interests. I
am concerned that people who live in a level of fear (resultant from coercive and
controlling behaviour) may have their decision-making abilities negatively affected and
the law surrounding capacity, as currently drafted, does not recognise this.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisation has the power to take such action.
7
YOUR RESPONSE
3
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 30th 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:
(i)
(ii)
(iii)
(iv)
(v)
Joanna’s family
Somerset Foundation Trust
Avon & Somerset Constabulary
Somerset Council Adult Social Care
Langport Surgery
I have also sent it to the following who may find it useful or of interest.
• Refuge of
• Women’s Aid of
• SafeLives of
• AAFDA of
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
5th March 2026
4
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.
Minister of State for Care
39 Victoria Street
London
SW1H 0EU
Samantha Marsh
Senior Coroner for the coroner area of Somerset
Old Municipal Buildings,
Corporation Street,
Taunton, Somerset
TA1 4AQ
16 April 2026
Dear Samantha,
Thank you for the Regulation 28 report of 5th March 2026, sent to the Department of Health
and Social Care (DHSC), about the death of Mrs Joanna Hillard. I am replying as the Minister
with responsibility for adult social care Mental Capacity.
Firstly, I would like to say how saddened I was to read of the circumstances of Mrs Joanna
Hillard’s death; I offer my sincere condolences to her family and loved ones. The
circumstances your report describes are concerning and I am grateful to you for bringing
these matters to my attention.
I acknowledge your concern that coercive and controlling behaviour, fear and trauma may
affect a person’s ability to make and communicate decisions, even where capacity may be
assessed as present under the Mental Capacity Act (MCA) 2005.
The Prevention of Future Deaths (PFD) report raises concerns over:
1. Whether the Mental Capacity Act 2005 adequately reflects the impact of coercive and
controlling behaviour on decision-making.
2. Gaps and inconsistency in professional understanding of coercive control and fear
on victims’ choices and disclosures.
3. Limitations of safeguarding options where a person is assessed as having capacity
but remains at high risk.
4. The need for clearer multi-agency guidance and training on capacity, risk, evidence
and escalation in domestic abuse contexts.
In preparing this response, departmental officials have liaised with NHS England’s (NHSE)
South West Safeguarding Team. This was to establish whether NHSE had been made
aware of the lessons identified in your report, and to seek information on any relevant work
already under way, including follow-up action. While these teams had not previously been
sighted on the report, it has now been brought to their attention.
The Department for Health and Social Care has committed to delivering a range of new
policies that form part of the cross-government Violence Against Women and Girls (VAWG)
strategy, published in December 2025.
DHSC’s announcement of ‘Steps to Safety’ within the VAWG strategy will allow general
practice staff to identify, support and refer victims and survivors of domestic abuse and
sexual violence into wider support services. ‘Steps to Safety’ will also focus on identifying
early harmful behaviours and recognising early indicators of domestic abuse, enabling
earlier signposting and support before abuse begins or escalates.
The model will include:
•
training to all staff in the General Practices so they can identify and respond to
domestic abuse and sexual violence;
• a specialist support worker linked to a group of general practices to support General
Practice staff and support and advocate for victims;
• clear links with local specialist services to refer people into.
The Secretary of State also appointed Jess Asato MP as his advisor on
VAWG, reflecting his strong commitment to increasing the role the NHS plays in reducing
VAWG. The VAWG advisor is considering how the culture within the NHS can be shifted
to improve the health system’s response to better support victims and survivors.
NHS England is also strengthening national mandatory safeguarding training for all NHS
staff for launch in late 2026. It will reinforce to staff their safeguarding responsibilities and
support them in identifying and responding to victims of abuse, which includes those
experiencing coercive control.
The PFD report acknowledges that Joanna had access to Independent Domestic Violence
Advisors / Independent Sexual Violence Advisor support and was well known to
professionals but, due to the extent of the coercive control, could not take up the support.
Professionals were frustrated by their lack of powers to do much else as Joanna was
determined to have mental capacity to make decisions. It is hoped that the support we are
putting in place with ‘Steps to Safety’ will help identify domestic abuse earlier and
interventions put in place before abuse escalates.
Although section 76 Serious Crime Act 2015 offence post-dates the MCA, it was developed
and updated alongside the modern adult safeguarding framework (including the Care Act
2014 and the Domestic Abuse Act 2021) and is supported by statutory guidance: Controlling
or coercive behaviour: statutory guidance framework - GOV.UK. The MCA remains relevant
where coercion or undue influence interacts with an impairment or disturbance of the mind
or brain so that the person cannot make the specific decision, in such cases, practitioners
should complete and record a decision-specific capacity assessment. Where an adult has
capacity, the MCA is not a general route to override unsafe or unwise decisions, and other
safeguarding, civil and criminal routes may be more appropriate.
The current code doesn’t refer to coercive and controlling behaviour as these did not
constitute an offence until 2015, although there is the inference of the individual concerned
being influenced by a person. However, the draft Mental Capacity Act Code of Practice
consulted on in 2022, expressly recognises that coercion, undue influence and fear may
affect a person’s ability to use and weigh information when making decisions. The Court of
Protection has repeatedly recognised that controlling and coercive behaviour can undermine
genuine autonomy, even where a person appears cognitively able to decide.
The PFD report also indicates that a capacity assessment was undertaken. This underlines
that the presumption of capacity does not remove the need to assess where there is a proper
basis for doing so. We will make clear in the updated MCA Code of Practice (to be consulted
on) that practitioners should not equate “assume capacity” with “do not assess”.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Yours sincerely,
MINISTER OF STATE FOR CARE
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.