Prevention of Future Deaths reports · 2026

Oliver Roberts

Regulation 28 report to prevent future deaths, reference 2026-0184, written 30 Mar 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report30 Mar 2026
Reference2026-0184
DeceasedOliver Roberts
CoronerRachael Griffins
Coroner areaDorset
CategoryMental Health related deaths · Emergency services related deaths (2019 onwards)
Organisation namedDorset Healthcare University NHS Foundation Trust
Sourcejudiciary.uk record · original PDF
Responses published2

The report

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.  Chief Executive Officer of the College of Policing 

2.  Chair of the National Police Chiefs’ Council 

1  CORONER 

I am Rachael Clare Griffin, Senior Coroner, for the Coroner Area of Dorset. 

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 30th January 2024, I commenced an investigation into the death of Oliver John 
Roberts, born on the 10th May 1994, who was aged 29 years at the time of his 
death.  

The  investigation  concluded at  the  end  of the  Inquest  before  a  jury  on  the  27th 
March 2026.  

The medical cause of death was: 

Ia Hanging 

The conclusion of the jury was a narrative conclusion - Oliver John Roberts died 
as  a  consequence  of  self-suspension  by  ligature,  where  his  intention  remains 
unclear.  Oliver’s  death  was  contributed  to  by  failure  to  determine  appropriate 
level of risk. 

4  CIRCUMSTANCES OF THE DEATH 

On the 28th January 2024 Ollie was found suspended by a ligature in a wooded 
, Bournemouth, Dorset. At around 13.48 hours on the 27th 
area in 
January 2024, Derbyshire Police reported to Dorset Police that Ollie’s estranged 
wife had contacted  them  to  advise he  had  sent a  photograph  of  a  ligature  and 
then facetimed her with the ligature around his neck. He had a history of making 
threats  to  end  his  life  and  information  provided  to  the  police  was  that  he  was 
making threats for sympathy from his estranged wife to rekindle the relationship. 
Information was also obtained that he had called his son that day at 13.15 hours 
to say he would not see him again.  

Ollie  was  treated  as  a  missing  person  by  Dorset  Police  and  was  graded  as 
medium risk when the initial missing person risk assessment was undertaken by 
the  Force  Incident  Manager  at  16.00  hours  on  27th  January  2024.  Following  a 

 
 
 
 
 
 
 
 review recorded by an Inspector at 23.05 hours, Ollie was graded as a high risk 
missing person.  

A Grade 2 application for communications data was sent to the communication 
data investigation team at 12.32 hours on the 28th January 2024 which led to data 
being  provided  to  Dorset  Police,  which  led  to  Ollie  being  found  deceased  at 
approximately 14.40 hours that day. Evidence obtained after his death revealed 
Ollie was last known to be alive at 19.39 hours. 

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.  –  

(1)  There  is  a  lack  of  guidance  to  assist  Police  Officers  in  the  practical 
application  of their  powers  to  obtain communications  data,  whether that 
be under a Grade 1, 2 or 3 application.  

(2)  Communications  data  can  be  obtained  by  Police  forces in England and 
Wales  pursuant  to  the  Investigatory  Powers  Act  2016  (the  Act).  In 
November 2018 the Home Office issued the Communication Data Codes 
of Practice (the Codes of Practice) which is a document that extends to 
144 pages and relates to the exercise of functions conferred by virtue of 
Parts 3 & 4 of the Act.  

(3)  Requests are submitted by police representatives to their Communication 
Data Investigation Teams to access data, and this will be done in different 
ways depending on the grading of the request.  

(4)  Grade 1 requests are made when there is an immediate risk to life. Grade 
2 requests are made when there is an exceptionally urgent requirement 
for the prevention or detection of serious crime; a credible and immediate 
threat  to  national  security;  or  a  serious  concern  for  the  welfare  of  a 
vulnerable person where urgent provision of the communications data will 
have an immediate and positive impact on the investigation or operation. 
Grade 3 requests are made when matters that are not urgent but, where 
appropriate, will include specific or time-critical issues such as bail dates; 
court dates; where persons are in custody; or where there is a specific line 
of  investigation  into  a  serious  crime  and  early  disclosure  by  the 
telecommunications operator or postal operator will directly assist in the 
prevention or detection of that crime. 

(5)  Section  5  of  Codes  of  Practice  refers  to  the  application  process  and 
Section 6 deals with the authorisation of the application, however there is 
no  practical  guidance,  such  as  Authorised  Professional  Practice 
Guidance,  to  assist  Forces  and  their  officers,  as  to  how  and  when 
applications should be made and authorisations should be given.  

(6)  In this  case  a  Grade 2 application  was  submitted  almost  24  hours  after 
Ollie  was  reported  missing.  Once  submitted,  Ollie  was  found  within  2 
hours and 9 minutes. This application was submitted in writing, however 

 
 
 
 
 
 
 
 
 evidence was given that in some circumstances a verbal application for a 
Grade 2 request can be made if the Grade 2 application is urgent. There 
is  a  lack  of  guidance  to  police  officers  nationally  as  to  what  would 
constitute a Grade 2 urgent application and what should be done in writing 
and what should be done verbally.  

(7)  I am concerned that the circumstances of Ollie’s death could occur again 
as a result of the lack of practical guidance to Police Forces and their staff 
as to when and how to make data communication requests pursuant to 
the Investigatory Powers Act 2016. 

“6  ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you 
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 25th 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)  Ollie’s family 
(2)  Chief Constable of Dorset Police 
(3)  Chief Constable of Devon and Cornwall Police  
(4)  Dorset Healthcare University NHS Foundation Trust 

I am also 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 coroner, 
at the time of your response, about the release or the publication of your response 
by the Chief Coroner. 

9  Signed 

Rachael C Griffin 

HM Senior Coroner for Dorset 

30th March 2026

Responses

2 responses 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.

Response from College of Policing (PDF)
HM Coroner Rachael Griffin, 
The Coroner’s Office for the Count of Dorset, 
Civic Centre, Bourne Avenue 
Bournemouth 
BH2 6DY 

01 May 2026 

Regulation 28: Report to Prevent Future Deaths, Mr Oliver John Roberts, 10.05.1994. 

Dear HM Coroner Griffin, 

Thank you for your report into the tragic death of Mr Oliver John Roberts and I acknowledge the 
concerns that you have outlined in section 5 and our duty to respond.  

While you kindly outline the circumstances of Mr Roberts’ passing within your report, I thought it 
may be helpful to contextualise the below response with a succinct chronological narrative. As I 
understand it, Mr Roberts was reported missing on 27th January 2024 at 13:48. The Force Incident 
Manager classified this report as ‘medium risk,’ at 16:00 on that same date. The last time that Mr 
Roberts was known to be alive was provided as 19:39. At 23:05 on that same date, the missing 
report was upgraded to ‘high risk.’ At 12:32 on 28th January 2024, a Grade 2 application was sent 
to the CDI Team. Tragically, Mr Roberts was found deceased at 14:40. I have provided a reply 
under each point that you have referenced as matters of concern.  

Matters of Concern 

1.  There is a lack of guidance to assist Police Officers in the practical application of 

their powers to obtain communications data, whether that be under a Grade 1, 2 or 
3 application.  

There  is  eLearning  training  that  is  available  for  investigators  on  our  national  ‘College  Learn,’ 
platform. These learning packages “Introduction to Communications Data,” sit within the Digital 
Media Investigators (DMI) modules. Within this training there is emphasis on Grade 1’s requiring 
an ‘immediate threat to life, and Grade 2’s requiring  …” a serious concern for the welfare of a 
vulnerable person where urgent provision of the communications data will have an immediate and 
positive impact on the investigation or operations.” This training is available for all police officers 
and staff across England and Wales. (Please also see my response to point five, for additional 
available training).  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2.  Communications  data  can  be  obtained  by  Police  forces  in  England  and  Wales 
pursuant to the Investigatory Powers Act 2016 (the Act). In November 2018 the Home 
Office  issued  the  Communication  Data  Codes  of  Practice  (the  Codes  of  Practice) 
which  is  a  document  that  extends  to  144  pages  and  relates  to  the  exercise  of 
functions conferred by virtue of Parts 3 & 4 of the Act. 

Although I recognise that the June 2025 Home Office Communications Data Code of Practice 
publication postdates Mr Roberts’ passing, I would hope that you are also reassured by section 
5.47,  which  outlines  the  circumstances  in  which  an  urgent  authorisation  may  be  appropriate, 
reading,  “an  immediate  threat  of  loss  or  serious  harm  to  human  life  -  this  may  include  those 
situations  where,  for  example,  there  is  serious  concern  for the  welfare  of  a  vulnerable  person 
including children at imminent risk of being abused or otherwise harmed.”  

3.  Requests are submitted by police representatives to their Communication Data 
Investigation Teams to access data, and this will be done in different ways 
depending on the grading of the request.  

All communications data (CD) applications are requested by an applicant using the force workflow 
system.  The  UK  has  three  workflow  platforms,  ‘Charter,’  ‘Cycomms,’  and  ‘Optica.’  The 
authorisation  body,  which  is  the  Investigatory  Powers  Commissioners’  Office-  Authorisations 
(IPCO-A) has access to each of these systems to review and authorise  individual applications 
and all can facilitate urgent oral applications.  

4.  Grade 1 requests are made when there is an immediate risk to life. Grade 2 

requests are made when there is an exceptionally urgent requirement for the 
prevention or detection of serious crime; a credible and immediate threat to 
national security; or a serious concern for the welfare of a vulnerable person 
where urgent provision of the communications data will have an immediate and 
positive impact on the investigation or operation. Grade 3 requests are made when 
matters that are not urgent but, where appropriate, will include specific or time-
critical issues such as bail dates; court dates; where persons are in custody; or 
where there is a specific line of investigation into a serious crime and early 
disclosure by the telecommunications operator or postal operator will directly 
assist in the prevention or detection of that crime.  

Acknowledging the grading criteria, and the available training (referenced in my response to point 
1 and 5 below), we are also in the process of developing further training for the ‘CD Single Point 
of Contact (SPoC) community; particularly with the development of a Hydra (immersive learning) 
exercise around fast-time decision making in this space. We anticipate that this will be piloted in 
Summer 2026. 

5.  Section 5 of Codes of Practice refers to the application process and Section 6 
deals with the authorisation of the application, however there is no practical 
guidance, such as Authorised Professional Practice Guidance, to assist Forces 
and their officers, as to how and when applications should be made and 
authorisations should be given.  

 
 
 
 
 
 
 
 
 
 
 In  addition  to  the  referenced  College  training,  in  collaboration  with  the  National  Action  Fraud 
Network,  IPCO-A,  HMRS  and  Home  Office,  we  have  produced  a  further  training  product, 
“Standardising  Communications  Data  Applications,”  which  is  available  on  the  NCDS  website. 
Some organisations have taken the decision to mandate this training for staff.  

6.   In this case a Grade 2 application was submitted almost 24 hours after Ollie was 
reported missing. Once submitted, Ollie was found within 2 hours and 9 minutes. 
This application was submitted in writing, however evidence was given that in 
some circumstances a verbal application for a Grade 2 request can be made if the 
Grade 2 application is urgent. There is a lack of guidance to police officers 
nationally as to what would constitute a Grade 2 urgent application and what 
should be done in writing and what should be done verbally. 

The  training  for  communications  data  specialists  provides  guidance  for  what  constitutes  the 
specific purposes for communications data, and the priority grading for the disclosure of the data 
by telecommunications operators. The training also details how quickly the IPCO-A can consider 
a written application regarding its authorisation. Grade 2 authorisations can be approved by IPCO 
at  short  notice  during  08:00  –  22:00hrs  daily.  A  Grade  2  application  would  not  be  processed 
outside  of  these  times,  so  the  grading  could  have  had  an  impact  if  requested  outside  of  their 
working hours. There is no guidance as to precisely when an application must be written (most 
are), but the communications data SPoC will act as a guardian and date keeper for applications, 
and for Authorising Individuals to authorise or otherwise.  

7.  I am concerned that the circumstances of Ollie’s death could occur again as a result 
of the lack of practical guidance to Police Forces and their staff as to when and how 
to  make  data  communication  requests  pursuant  to  the  Investigatory  Powers  Act 
2016.  

While I am not privy to any further detail of the investigation, (and cede to any new information 
that could cast light on the following) the concern here may be around the initial risk assessment 
and speed of application submission, rather than the grading or guidance. According to the IPCO 
Service Level Agreement, Priority two data, has a six-hour turnaround, for example.  

I have tasked my team with examining where the Missing Persons Authorised Professional 
Practice could be further strengthened in this area to provide greater clarity and direction around 
communications data and tracking, during the current review process.  

Finally, I wanted to extend my condolences to Mr Roberts family and friends  and reassure you 
that we will continue to review where and how we can strengthen training and guidance to ensure 
that policing is better equipped to help vulnerable people in their times of need. 

 
 
 
 
 
 
 
 
 
 Yours sincerely,  

Chief Executive Officer 
College of Policing 

www.college.police.uk
Response from The National Police Chiefs Council (PDF)
National Police Chiefs’ Council
   50 Broadway
London
SW1H 0BL

April 2026

HM Senior Coroner Rachael Griffin
Senior Coroner, Area of Dorset.

By email

Dear Senior Coroner Griffin,

I write on behalf of the National Police Chiefs Council (NPCC) in relation to paragraph 7, Schedule 5 of
the Coroners and Justice Act 2009, and regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013, in relation to the prevention of future deaths report sent via email to the NPCC dated
30th March 2026.

The notice sets out concerns that arose from the information received during the inquest into the death
of Oliver Roberts. I am very sorry to read of the circumstances of Oliver’s death. My sympathies are
with his family and friends.

I understand that the matters of concern raised are as follows:

1.  There is a perceived lack of practical guidance to support police officers in the application of

their powers to obtain communications data, whether under Grade 1, 2 or 3 requests.

2.  Communications data is obtained pursuant to the Investigatory Powers Act 2016 (IPA). The
Home Office issued the Communications Data Codes of Practice in November 2018, a
comprehensive document of approximately 144 pages addressing the exercise of functions
under Parts 3 and 4 of the Act.

3.  Requests for communications data are submitted by operational officers to Communications
Data Investigation Teams, with processes varying depending on the grading of the request.
4.  Grade 1, 2 and 3 requests are defined within the Codes of Practice, with Grade 1 relating to an
immediate threat to life, Grade 2 to exceptionally urgent matters (including serious concern for
the welfare of a vulnerable person), and Grade 3 relating to non-urgent but time-critical issues.

5.  While sections 5 and 6 of the Codes of Practice address the application and authorisation

processes, there is concern that more practical guidance—similar to Authorised Professional
Practice—does not exist to support officers in decision-making.

6.  In this case, a Grade 2 application was submitted almost 24 hours after Oliver was reported
missing, following which he was located within just over two hours. Evidence was heard that
urgent Grade 2 requests may be made verbally, yet there is no clear national guidance setting
out when verbal or written applications should be used.

7.  The Court is concerned that, without clearer guidance, similar circumstances could arise again.

In providing a response to these matters of concern, various portfolios within the NPCC have been
consulted. While Oliver was reported as a missing person, the concerns identified relate more broadly
to the use of communications data where there is serious concern for the welfare of a vulnerable
person. This applies regardless of whether the individual has been formally reported missing.

From the perspective of the NPCC Missing People Working Group, operational guidance already
directs investigating officers to seek advice from their Communications Data Investigators or Single

 Points of Contact (SPoCs). These specialists are trained experts in the Investigatory Powers Act 2016
and are best placed to advise whether a Grade 1 or Grade 2 application is appropriate.

I am not aware of any national guidance that prescribes when an operational officer must submit a
communications data request. Decisions regarding grading, urgency, and whether a request should be
made verbally or in writing properly sit with communications data SPoCs. In making those decisions,
SPoCs are expected to undertake a risk assessment, apply the statutory thresholds, and fully document
their decisions and actions.

The Communication Data Codes of Practice clearly describe the grading structure, as well as the
circumstances in which urgent oral authorisation may be appropriate. SPoCs are expected to consider
all relevant factors set out within the Codes when determining how best to proceed.

It is also relevant to note that force capabilities vary. For example, West Yorkshire Police operate a 24/7
Communications Data Investigation Unit with an on-duty SPoC at all times, accessible to operational
staff. Other forces may still operate on an on-call basis, which can affect local processes but does not
alter national legal thresholds. Due to the difference in processes across force areas, each force
remains responsible for ensuring that suitable risk-based training is provided for staff. This would be
especially true for officers at the rank of Sergeant or Inspector, who would normally undertake a risk
assessment and set relevant investigative actions – including the consideration to request
communications data.

In providing this response, we have worked closely with the College of Policing, who lead in areas such
as setting national policing standards, including the provision of Authorised Professional Practice
(APP). I will not seek to repeat the information that they have provided to you, other than to support
their comments around the training and national guidance that already exists and is readily available to
officers and staff. I welcome their ongoing process of developing further training specifically for the
communications data SPoC community, focused on fast-time decision-making.

I am also reassured that the College are in the process of reviewing the Missing Persons Authorised
Professional Practice and whether it can be further strengthened. The NPCC remains committed to
supporting Forces and other stakeholders to continually improve the wider policing response with
respect to investigations where communications data is pertinent.

I hope that this response provides reassurance and addresses the concerns raised by the Court.
Please do not hesitate to contact me should you require any further information or clarification.

Yours sincerely,

Chair
National Police Chiefs’ Council

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