Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0162, written 17 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 | 17 Mar 2026 |
|---|---|
| Reference | 2026-0162 |
| Deceased | Natalie Ainsworth |
| Coroner | Janine Richards |
| Coroner area | County Durham and Darlington |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 The Chief Constable of Durham Police 1 CORONER I am Janine RICHARDS, 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 14/02/2025 12:05an investigation was commenced into the death of Natalie Louise AINSWORTH 13/10/1995. The investigation concluded at the end of the inquest on 13/03/2026 00:00. The conclusion of the inquest was that Natalie Louise Ainsworth, aged 29 years, was found deceased on the 13th of February 2025 at 37 Tweed Terrace, Stanley, County Durham. 4 CIRCUMSTANCES OF THE DEATH Natalie Louise Ainsworth, aged 29 years, was found deceased on the 13th of February 2025 at 37 Tweed Terrace, Stanley, County Durham. 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) Natalie was a vulnerable missing person considered to be at medium risk. A call was made to Police on the 13th February 2025 at 15:01 hours expressing concern for Natalie's welfare and informing Police of a new address where she may be and informing Police that she had earlier threatened to take her own life. Although the control room recorded that information was passed on to the relevant officer, neither the Inspector who undertook an updated a risk assessment some two hours later, nor the Officer making enquiries, was aware that Natalie had threatened to take her own life. This important information was therefore not part of the risk assessment and not factored into subsequent Police actions, including in terms of whether to force entry to the property which was visited by the Police. Further the risk assessment carried out at 1704 hours was not a robust assessment of the risks which were known, or ought to have been known, by Police at that time. In particular the risk assessment fails to consider Natalie's vulnerability as a person with a history of mental health issues, self harm and substance abuse, records incorrectly that Regulation 28 – After Inquest Document Template Updated 30/07/2021 there is no indication that the person is likely to take their own life, records incorrectly that the person has no mental health issues, and records incorrectly that the person has not been involved in a violent incident prior to them disappearing. An accurate and robust assessment of risk is essential to ensure that the nature and extent of any Police response is proportionate, and resources deployed appropriately, particularly when welfare/safety concerns are raised, as they were in Natalie's case. 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 May 12, 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 Police and Crime Commissioner 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 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: 17/03/2026 Janine RICHARDS Assistant Coroner for County Durham and Darlington Regulation 28 – After Inquest Document Template Updated 30/07/2021
11th May 2026 To: HMAC Janine Richards Dear HMAC Richards I write in response to the Regulation 28 Report to Prevent Future Deaths which was issued to the Chief Constable of Durham Constabulary in relation to Natalie Louise Ainsworth, date of birth 13/10/1995, following the conclusion of the inquest on 13/03/2026. Firstly, I would like to express my sincere condolences to Natalie’s family and friends. I recognise the profound loss they have experienced, and my thoughts are with them at this very difficult time. It is vitally important that any learning arising from these circumstances are identified and acted upon. I have carefully considered the concerns raised and have sought assurance from Durham Constabulary regarding the actions taken in response to your Report. The Constabulary has undertaken a review of its processes concerning the recording and management of additional information received within the Force Control Room during missing person investigations. As a result, improvements have been implemented to strengthen both the recording and communication of such information. Specifically, Control Room staff are now required to input any new or updated information directly into the missing person enquiry log. In addition, they must make direct contact with the investigating officer to ensure that they are aware of the update and its location within the log. The Control Room Incident (Storm) log will also clearly record that this action has been completed. These measures will ensure that all relevant information is clearly documented, readily accessible to those conducting enquiries, and available to supervisors responsible for reviewing risk assessments. Furthermore, I am advised that, in the period between Natalie’s death and the conclusion of the inquest, the Constabulary had already reviewed its Missing From Home Policy and Guidance. This was supported by updated training for officers and staff, with a particular focus on recognising vulnerability, identifying risk factors, and determining the appropriate operational response. DURHAM POLICE AND CRIME COMMISSIONER Police Headquarters, Aykley Heads. Durham DH1 5TT| Call: 0191 375 2001 | Email: general.enquiriesPCC@durham-pcc.gov.uk | Online: www.durham-pcc.gov.uk In my role as Durham Police and Crime Commissioner I am satisfied that these actions demonstrate a clear commitment by Durham Constabulary to learning and continuous improvement. I will continue to hold the Chief Constable to account to ensure that these changes are fully embedded and effective in practice. Yours sincerely Durham Police and Crime Commissioner DURHAM POLICE AND CRIME COMMISSIONER Police Headquarters, Aykley Heads. Durham DH1 5TT| Call: 0191 375 2001 | Email: general.enquiriesPCC@durham-pcc.gov.uk | Online: www.durham-pcc.gov.uk
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.
Durham Constabulary Assistant Chief Constable Chief Constable’s Office Constabulary Headquarters Aykley Heads DURHAM County Durham DH1 5TT 12th May 2026 Dear Ms Richards Durham Constabulary Response to the Regulation 28; Report To Prevent Future Deaths relating to the case of Natalie Louise AINSWORTH DOB 13/10/1995 issued at conclusion of the inquest on 13/03/2026 Since the issuing of the notice the Force have reviewed processes around the recording of additional information received into the Force Control Room as part of a missing person investigation. As a result, changes have been made to how that information is recorded and shared with those engaged in enguiries to locate the missing person and to ensure that all information is readily available to those conducting reviews of risk assessments. The new process is that the member of Control Room staff will now directly input the new or updated information into the missing person enquiry log whilst also making direct contact with the Investigating Officer to ensure that they are aware of the update’s presence in that log. The Control Room Incident (Storm) log will also reflect that this entry has been made, recording the detail of the message passed to the Investigating Officer alongside the time of the update. (For example Officer A was contacted by radio at 1300 hours and informed of the newly identified address, 123 High Street.) This will ensure that a clear record of the update is available to the Investigator and subsequent reviewing Supervisor. In the period between the death of Natalie AINSWORTH and the inquest conclusion the Constabulary had already reviewed it’s Missing From Home Policy and Guidance and provided updated training to those conducting risk assessments. This focused around the recognition vulnerability and other risk factors and determining the appropriate response as a result. facebook www.durham.police.uk DU CO RHAM NSTABULARY I N A N h ■ O , U h ' ■ EMERGENCY ALWAYS CALL 9 9 9 I trust that I have provided enough information to deal with your report but should you require any additional information please do not hesitate to contact me. Yours sincerely Assistant Chief Constable Ms Janine Richards Assistant Coroner for County Durham and Darlington 2
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