Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2026-0153, written 22 Dec 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Dec 2025 |
|---|---|
| Reference | 2026-0153 |
| Deceased | Wendy Eyles |
| Coroner | Hassan Shah |
| Coroner area | Northamptonshire |
| Category | Railway related deaths · 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Assistant Director, Northamptonshire Healthcare NHS Foundation Trust 2 Northamptonshire Integrated Care Board 1 CORONER I am Hassan SHAH, Assistant Coroner for the coroner area of Northamptonshire 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 04 November 2024 I commenced an investigation into the death of Wendy Siobhan EYLES aged 55. The investigation concluded at the end of the inquest on 15 December 2025. The conclusion of the inquest was that: Wendy Siobhan Eyles died on the 31st October 2024 when she was struck by a train at Kettering station, having climbed down from the platform. Appropriate mental health support and intervention had not been provided. 4 CIRCUMSTANCES OF THE DEATH Wendy Siobhan Eyles died 31.10.2024 when she was struck by a train at Kettering Station having climbed down from the platform. Appropriate mental health support and intervention had not been provided. The medical cause of death was:- 1a Multiple traumatic injuries. The conclusion was Suicide. 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) One of the findings of the the Patient Safety Incident Investigation (PSII) was that “.. there is no protocol for patients open to private and NHS psychiatry at Northamptonshire Healthcare Foundation Trust. The Psychiatrist’s role in patient care is to review and recommend appropriate medication and it is problematic if two Consultants are overseeing this at the same time. It can cause confusion and detriment to the patient if medication changes are not communicated between parties and represents a risk to patient safety… It Regulation 28 – After Inquest Document Template Updated 30/07/2021 is notable that CMHT operational managers from across the service differ in their views on the appropriateness of a patient being open to NHS and private services at the same time..”. It also emerged at Inquest that a NHS Consultant may not be aware that the patient is also receiving private psychiatry. Where the GP is notified of private psychiatry, it does not trigger a notification to NHS mental health services. Notification of the dual treatment may then be entirely dependent upon the information being shared by the patient. 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 February 16, 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 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: 22/12/2025 Hassan SHAH Assistant Coroner for Northamptonshire 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.
CHAIR AND CEO OFFICE Berrywood Hospital Berrywood Drive NORTHAMPTON NN5 6UD Date: 12 February 2026 Mr H Shah Assistant Coroner for Northamptonshire The Guildhall St Giles' Square Northampton NN1 1DE Dear Mr Shah Regulation 28 Report Concerning Wendy Siobhan Eyles Thank you for your Report to Prevent Future Deaths (‘Report’) dated 22 December 2025 concerning the death of Wendy Siobhan Eyles on 31 October 2024. Before responding to the matters of concern you have included within your Report, I would like to express my condolences to Ms Eyles’ family and loved ones. The matters of concern in your Report centre on the safeguards in place when a patient is receiving NHS and private psychiatric care simultaneously. Specifically, you highlighted the lack of a protocol within the Trust when, and the lack of a notification trigger if/when a GP becomes aware that, a patient is receiving private and NHS care. You have asked the Trust to provide details of action taken, or proposed to be taken, or to explain why no action is proposed. Accordingly, please find below our response to your concerns detailing the actions we will take. Protocol for patients receiving NHS and private psychiatry Patient safety is of paramount importance to NHFT. We understand that there are risks to a patient’s safety when they are receiving private psychiatric care alongside our own treatment plan. To manage these risks, we are developing a new private care protocol. Cont’d/… Trust Headquarters: St. Mary’s Hospital, London Road, Kettering, NN15 7PW This new private care protocol will guide clinicians throughout the organisation on how to approach circumstances when it becomes known that their patient is accessing care from a private healthcare provider. It will operate within our existing policy framework, linked to existing policies and procedures for information sharing and record keeping. Work to develop this new protocol is underway and will be completed by the end of this month. Once in place it will apply to new and existing patients. Please let me know if you would like to receive a copy of the protocol and I shall arrange for it to be sent to you. While recognising the improvement this new protocol will deliver, it is important to remember that neither the patient themselves nor a private healthcare provider is obliged to inform us when they are receiving private psychiatric care. Sharing information when patients are accessing private psychiatry I note that you sent a copy of your Report to the Northamptonshire Integrated Care Board (NICB), as the body responsible for commissioning primary care services from GPs. Since receiving your Report, we have been in dialogue with the NICB about the steps we can take to facilitate an appropriate exchange of information with NHFT when a GP becomes aware their patient is simultaneously receiving NHS and private psychiatric care. In their response to your Report, the NICB will confirm the specific actions they have taken to encourage the GPs they commission to notify us when a patient is receiving private psychiatric care while adhering to information governance requirements. I hope the content of this letter fully addresses the concerns you raised in your Report and provides assurance on the steps we will take to prevent future deaths. Please contact me if you have any questions about this letter or require further information. Yours sincerely Chief Executive Cc , Chief Nurse , Managing Director and Deputy Chief Executive Chief Medical Officer , Chief Operating Officer Trust Headquarters: St. Mary’s Hospital, London Road, Kettering, NN15 7PW
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