Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0133, written 6 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 | 6 Mar 2026 |
|---|---|
| Reference | 2026-0133 |
| Deceased | Asher Blackman |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Other related deaths |
| Organisation named | Central London Community Healthcare NHS Trust |
| 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. Central London Community Healthcare NHS Trust 1 CORONER I am Mr Andrew Walker, senior coroner for the coroner area of Northern London 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 29 September 2025 I commenced an investigation into the death of, Asher Blackman, aged 72. The investigation concluded at the end of the inquest on17 December 2025. The conclusion of the inquest was consequences of diabetes. 4 CIRCUMSTANCES OF THE DEATH On the 21st September 2025, Asher Blackman died in hospital having collapsed at his home, where he was found to be profoundly hypoglycaemic. It is unclear why he became so hypoglycemic as no District Nurse visited the evening before to provide his insulin injection. It is likely than an imbalance between his food and insulin caused the hypoglycaemia. Had the District Nurse been able to get access to Mr Blackman, a blood sugar reading would have been taken and an opportunity to treat Mr Blackman was therefore missed. CORONER’S CONCERNS 5 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. – That the initial assessment for Mr Blackman by the District Nurses did not record his next of kin details or what to do should the district nurse not be able to gain access. The policy following no access did not take into account the need for police involvement where the life of the patient may be at risk through non access. 1 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 You are under a duty to respond to this report within 56 days of the date of this report, namely by Friday 01 May 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: 1. The family. 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 DATE: 06 March 2026 2
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.
Chief Nursing & People Officer Ground Floor 15 Marylebone Road London NW1 5JD Mr Andrew Walker Senior Coroner Northern London Coroner’s Court 27th April 2026 Dear Mr Walker Re: Response to Regulation 28 Report to Prevent Future Deaths – Asher Blackman Thank you for your Prevention of Future Deaths (PFD) report dated 06 March 2026, following the inquest into the death of Mr Asher Blackman, which concluded on 17 December 2025. On behalf of Central London Community Healthcare NHS Trust (CLCH), I would like to express again our sincere condolences to Mr Blackman’s family. The Trust has carefully reviewed the matters raised in your report and, to ensure that we fully reflect on and learn from the events leading to the death of Mr Blackman, has undertaken a programme of Trust wide engagement events. These sessions have been designed to review clinical practice and the application of the ‘No Access: Not Seen: Disengagement Policy’, ensuring that current approaches to managing situations where clinical staff are unable to gain access to a patient appropriately identify and assess all potential risks, and that proportionate mitigations are implemented to meet individual patient need. ‑ We have undertaken engagement events which have been well received and attended by approximately 420 staff to date. The sessions have supported the reinforcement of the requirement to ensure clinical records are comprehensive in all situations and contain where possible verified next of kin and emergency contact details completed at the first point of contact. Below is the detailed response from CLCH addressing the concerns you outlined. Matter of Concern 1 The initial District Nursing assessment did not record next of kin details or provide clear instructions regarding the actions to be taken should access to the patient not be obtained. Response: - 2 - The Trust has undertaken a review of District Nursing referral forms, initial assessment documentation, and clinical system configurations to ensure that: • Next of kin and emergency contact details are mandatory fields and are completed at triage where the information is available and if this not available, staff are expected to obtain this from the patient at the first visit. • Electronic patient record systems display essential patient information prominently on the front page of the record to improve accessibility. In addition, the Trust has a long-term plan to improve visibility of this information on the system, and we are working with the Information Management Team to update the electronic patient record system to include prompts and alerts to support completion and verification of this information. Matter of Concern 2 The policy relating to non access did not sufficiently address the need for police involvement where a patient’s life may be at risk as a result of repeated failure to gain access. ‑ Response: The No Access: Not Seen: Disengagement Policy states that, while police involvement is not routine, it is both justified and expected where a failure to gain access gives rise to immediate or escalating concerns regarding patient safety or risk to life. The policy further provides for escalation to emergency services, including the police, where urgent visual confirmation of a patient’s wellbeing is required; where access is obstructed by others and there are genuine concerns regarding safety; or where non access indicates a risk of significant harm or death. In accordance with the Right Care, Right Person framework which is a National (England/Wales) Police policy, the Trust policy requires staff to frame any request for police assistance by explicitly articulating the specific risk posed by the patient to themselves and/or others, rather than requesting a general welfare check. ‑ Notwithstanding the existence of this Trust policy, the Trust is currently undertaking a comprehensive review informed by recent staff engagement activities. This review is intended to strengthen the policy by placing greater emphasis on the immediate escalation of a “no access” visit where a patient is assessed as being at significant clinical risk, including cases requiring critical interventions such as blood glucose monitoring and insulin administration. The Trust will also be providing patients with additional information about how it will support them in circumstances where there is no access. The Trust acknowledges the seriousness of the issues identified and remains fully committed to continuous improvement to prevent recurrence. The actions described above have been reviewed through the Trust’s clinical governance and patient safety frameworks. Compliance with revised processes will be monitored through established quality assurance mechanisms, including documentation audits, staff feedback, and incident review processes. The Trust remains firmly committed to learning from this case and to strengthening systems, processes, and clinical practice to reduce the risk of similar incidents occurring in the future. Conclusion - 3 - Central London Community Healthcare NHS Trust has formally reviewed the incident in accordance with its Patient Safety Incident Response Framework (PSIRF) and has identified opportunities to enhance existing processes. The Trust is assured that the actions implemented to embed improvements within the No Access: Not Seen: Disengagement arrangements, together with the proportionate PSIRF response, directly address the concerns raised in your report and significantly strengthen safeguards for patients receiving community nursing services. In addition to the engagement events, the Trust has taken steps to refresh staff knowledge on how to respond safely and appropriately to instances of no access, aligned with the concerns you have raised. We trust that this response provides assurance that appropriate and proportionate actions have been taken to mitigate the risk of future incidents of this nature. Please do not hesitate to contact us should you require any further information or clarification. Yours sincerely Chief Nursing & People Officer Charlie Sheldon Chief Nursing & People Officer
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