Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0140, written 11 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 | 11 Mar 2026 |
|---|---|
| Reference | 2026-0140 |
| Deceased | Janette Palmer |
| Coroner | Nigel Parsley |
| Coroner area | Suffolk |
| Category | Community health care and emergency services 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 FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1 Minister of State for Care sent via Department of Health and Social Care 1 CORONER I am Nigel Parsley, Senior Coroner, for the coroner area of Suffolk. 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 INVESTIGATION and INQUEST On 5th March 2025 I commenced an investigation into the tragic death of- Janette Margaret PALMER The investigation concluded at the end of the inquest on 10th March 2026. The conclusion of the inquest was that Janette Palmer died as the result of:- Accidental death, contributed to by frailty of old age and underlying poor health. The medical cause of death was confirmed as: 1a 2 Bronchopneumonia Frailty of Old Age and Left Hip Fracture. 4 CIRCUMSTANCES OF THE DEATH Janette Palmer’s death was verified at 15:15 on the 24th February 2025, at the St Nicholas Hospice, Bury St Edmunds, in Suffolk. Janette had been admitted to the St Nicholas Hospice on 21st February 2025 from the West Suffolk Hospital, Bury St Edmunds. Janette was admitted to the West Suffolk Hospital on 15th February 2025 following an unwitnessed fall she had suffered at her home address in which she suffered a fracture to her left hip. Upon admission it was identified that Janette had also had a heart attack (myocardial infarction), although whether or not this occurred before or after her fall could not be established. Janette also suffered from a number of significant co-morbidities, and a surgical procedure to repair her hip could not be attempted. Janette went onto develop a serious chest infection (bronchopneumonia) and her Regulation 28 – After Inquest Document Template Updated 30/07/2021 condition continued to deteriorate until her sad death. At the time of her fall on the 14th February 2025, an electrical power cut at her independent living housing for elderly individuals (Chestnut Court run by Havebury Homes Partnership) had occurred, meaning that none of the lights were on in Janette’s flat when she was found. Whether or not the lights were out at the time of Janette’s fall, and whether or not the lights being out contributed to her fall, could not be established on the available evidence. 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: In evidence it was heard from UK Power Networks (Operations) Ltd that a power outage in the area of Janette’s supported living accommodation had occurred on the 14th February 2025. The UK Power Networks (Operations) Ltd confirmed that Chestnut Court was not on their Priority Services Register and therefore did not qualify for additional support during the electrical outage. The additional support offered to properties on the Priority Services Register includes regular call backs with updates, SMS messaging updates, torches, battery back-up packs, the supply of hot food and drink, and if needed hotel accommodation. In their evidence Havebury Housing Partnership (the Housing Association which runs Chestnut Court) stated that it had no knowledge that a Priority Services Register existed, or knowledge of the enhanced response available if their properties were on that register. Given the circumstances of Janette’s case, it is not suggested that had Chestnut Court been on the Priority Service Register her tragic death would not have occurred. However, I am concerned that the lack of knowledge that the UK Power Networks Priority Services Register actually exists, may just not relate to the Havebury Housing Partnership but also to the many other providers of care home and sheltered housing facilities. I am concerned that in different circumstances, such as an extreme weather event, residents of other care homes and sheltered housing will not benefit from the enhanced response available and deaths may occur, due to a lack of knowledge of the UK Power Networks Priority Services Register by the individuals or businesses running those facilities. 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, Regulation 28 – After Inquest Document Template Updated 30/07/2021 namely by May 06, 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. Janette’s next of kin. 2. Havebury Housing Partnership I am under a duty to send the Chief Coroner a copy of your response. 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 Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Dated: 11/03/2026 Nigel PARSLEY HM Senior Coroner for Suffolk 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.
HM Coroner Nigel Parsley Suffolk Parliamentary Under-Secretary of State for Public Health and Prevention 39 Victoria Street London SW1H 0EU 23rd April 2026 Dear Mr Parsley, Thank you for the Regulation 28 report of 11/03/2026 sent to the Secretary of State / the Department of Health and Social Care regarding the death of Janette Palmer. I am replying as the Minister with responsibility for Emergency Preparedness and Health Protection. Firstly, I would like to say how saddened I was to read of the circumstances of Janette’s death and 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. The report raises concerns over the lack of knowledge of the Priority Services Register and the enhanced support it could have offered at Janette’s housing association. There is concern that this may not be limited to the one Housing Partnership but also to the many other providers of care homes and sheltered housing facilities. The concern is extended to consider that in circumstances such as an extreme weather event, residents of other care homes and sheltered housing will not benefit from the enhanced response available and harm may occur, due to a lack of knowledge of the UK Power Networks Priority Services Register by the individuals or businesses running those facilities. In preparing this response, my officials have made enquiries with the Care Quality Commission, the Department for Energy Security and Net Zero (DESNZ), and Cabinet Office, to ensure we adequately address your concerns. The Government is committed to ensuring effective emergency response and recovery. The Government’s approach to this was detailed in the Resilience Action Plan, published last year, which sets out how the Government will improve the nation’s domestic resilience and ability to respond to and recover from a range of potential emergencies. The Action Plan includes a number of specific measures the Government is taking to embed better understanding of the needs of vulnerable people in emergencies. The Department of Health and Social Care works closely with NHS England and other partners across the health and care system to plan for a range of resilience related risks. This includes a programme of work DHSC is undertaking to prepare the health and social care sector for the risk of disruption to key utilities, including power outages and severe weather. The health sector has resilience measures embedded to mitigate power outages, and we work with other government departments to continuously build our capabilities. The Priority Services Register website has been designed to be a single reference point for the NHS, local authorities, charities, and other partners to direct their service users towards. Various organisations including energy providers, Ofgem and the Met Office actively provide guidance on what to do in a power outage, guidance for those receiving and providing care, as well as promotion of the PSR. For example: https://www.ofgem.gov.uk/information-consumers/energy-advice-households/join-your- suppliers-priorit… What to do in a power cut - Met Office Ahead of winter each year, network operators run campaigns to advise customers of a general risk of power cuts/disruption over winter, advising on actions to prepare for potential winter energy disruption, and explicitly promoting enrolment to the Priority Services Register (PSR). This includes prompting existing PSR customers to update personal information, targeted leaflet distributing, and contacting medically dependent and PSR customers with advice. The Government has launched gov.uk/prepare, Prepare. This is a new government resilience website which will provide individuals, households and communities with information to enable them to be more prepared for emergencies. The website provides clear guidance on the Priority Services Register, including information about eligibility and how to sign up, with the intention of increasing registrations among those who may benefit most from the service. Furthermore, published guidance on identifying and supporting persons who are vulnerable in an emergency is aimed at Local Resilience Forums and recommends that local partners and emergency services should remind individuals who think they might need additional support during an emergency of the existence of Priority Service Registers. We are determined to ensure that all those receiving and providing care are aware of the PSR and the benefits it can provide, especially to vulnerable people and people with medical devices. In addition to the existing communications activities outlined above, we will be circulating clear guidance on the PSR to all care providers via the Adult Social Care Operational Resilience Forum and the Care Quality Commission monthly bulletin, who will cascade this to all of their care providers and networks. This will ensure that all individuals and carers have the necessary information they need to ensure vulnerable people are safe and supported. The guidance will outline how individuals and carers can sign up for the PSR, how to sign up for each of the utilities, as well as highlight both the benefits and the limitations of the PSR. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely,
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