Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0208, written 9 Apr 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Apr 2026 |
|---|---|
| Reference | 2026-0208 |
| Deceased | Richard Whelan |
| Coroner | Peter Merchant |
| Coroner area | West Yorkshire Western |
| Category | Mental Health related deaths |
| Organisation named | South West Yorkshire Partnership Teaching NHS Foundation 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 DEATHS THIS REPORT IS BEING SENT TO: 1 South West Yorkshire Partnership NHS Foundation Trust (SWYPT) 1 CORONER I am Peter Merchant, an Assistant Coroner for West Yorkshire (Western) jurisdiction. 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 19 December 2024 I commenced an investigation into the death of Richard Mark WHELAN aged 54. The investigation concluded at the end of the inquest on 02 April 2026 and the conclusion of the inquest was that: Richard Mark Whelan's death was confirmed at 14.30 hours on 15 December 2024 at his property . His death arose from exsanguination from incised wounds to both wrists. This was a deliberate act undertaken with the intention of ending his life although he subsequently made an attempt to rescue himself by leaving his property before collapsing on the pathway to his property. Subsequent attempts at CPR were unsuccessful. In the preceding weeks before his death there had been a deterioration in his mental health. An assessment by a Mental Health Practitioner did not identify the risk to warrant either an admission to hospital or further support from Mental Health Services, but with the agreement of Richard ,who had capacity, a Crisis Plan was formulated which Richard chose not to use. 4 CIRCUMSTANCES OF THE DEATH Richard Mark Whelan's death was confirmed at 14.30 hours on 15 December 2024 at his property 23 Greenacres, Sowerby Bridge. His death arose from exsanguination from incised wounds to both wrists. This was a deliberate act undertaken with the intention of ending his life although he subsequently made an attempt to rescue himself by leaving his property before collapsing on the pathway to his property. Subsequent attempts at CPR were unsuccessful. In the preceding weeks before his death there had been a deterioration in his mental health. As assessment by a Mental Health Practitioner did not identify the risk to warrant either an admission to hospital or further support from Mental Health Services, but with the agreement of Richard, who had capacity, a Crisis Plan was formulated which Richard chose not to use. In the time prior to his death, on 10 December 2024, he had disclosed that on 07 December 2024, he had taken an overdose with the intention of ending his life. On 10 December 2024, a neighbour had contacted his GP surgery expressing a concern for his welfare, resulting in the attendance at his address of two receptionists from the GP surgery and an ambulance crew. He had also been in close contact with a Neighbourhood Housing Officer. This resulted, with his consent, in a referral by the Neighbourhood Housing Officer Regulation 28 – After Inquest Document Template Updated 30/07/2021 to the Mental Health Trust Single Point of Access (SPA) Service on 11 December 2024. By the time of his death no action had been taken in respect of the referral. Evidence at the inquest suggested that a triage of any non-urgent referral may take up to 14 days and thereafter once triaged an initial plan to engage may be devised dependent upon the outcome of the triage. 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: Evidence at the inquest indicated that any referral to SPA classed as non-urgent may take up to 14 days to triage relecting the SPA Standard Operating Procedure. The referrals to SPA could come from anyone, not necessarily someone with experience of mental health conditions. It was only following a triage of a referral and the outcome of the triage would a plan be devised to take forward a referral. 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. The concern is the length of time take to triage such referrals. Recognising this is not only a provider but also a commissioning issue I will be copying this report to the Commissioners of the service. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 02 June, 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 of England & Wales and to the following Interested Persons: South West Yorkshire Partnership NHS Foundation Trust I have also sent a copy of my report to: West Yorkshire Integrated Care Board 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 of England & Wales 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 of England & Wales may publish either or both in a complete or redacted or summary form. The Chief Coroner of England & Wales may send a copy of this report to any person who she believes may find it useful or of interest. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 of England & Wales. 9 Dated: 09/04/2026 Peter MERCHANT HM Assistant Coroner for West Yorkshire Western Coroner Area 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.
2 June 2026 Mr Merchant HM Assistant Coroner, West Yorkshire (Western) HM Coroner’s Court Cater Building 1 Cater Street Bradford BD1 5AS Dear Sir Regulation 28 Response – Richard Whelan Chief Operating Officer Trust Headquarters – Block 7 Fieldhead Hospital Ouchthorpe Lane Wakefield WF1 3SP We write in response to the Regulation 28 report following the inquest touching the death of Mr Richard Whelan. We would like to start this response by offering Mr Whelan’s family our sincere condolences for their loss. We hope the information supplied in this response provides assurance that the Trust has carefully considered your concern, as noted below. Evidence at the inquest indicated that any referral to SPA classed as non-urgent may take up to 14 days to triage reflecting the SPA Standard Operating Procedure. The referrals to SPA could come from anyone, not necessarily someone with experience of mental health conditions. It was only following a triage of a referral and the outcome of the triage would a plan be devised to take forward a referral. The Trust has clear standards in place to ensure timely and appropriate access to care for all service users. The Trust’s current process is that all referrals are screened by a registered Single point of Access (SPA) practitioner within 48 hours. This process considers the content of the referral, including any risk information provided, together with relevant information available on the Trust's clinical systems or elsewhere in order to determine the appropriate level of urgency and care pathway. For those referrals identified as urgent through the screening process, assessment takes place within 24 hours. For those referrals identified as routine, assessment takes place within 14 days. The universal screening process therefore ensures that individuals receive care aligned with the severity and immediacy of their mental health presentation. The Trust accepts referrals from a wide range of agencies and professionals and also from individuals, their families and carers. In respect of referrals received from referrers with limited understanding of mental health conditions, the Trust is developing referral guidance to support referrers in recognising risk factors and understanding when immediate telephone contact with SPA is required. In addition, the referral form is being amended to include guidance that, where there are positive responses to risk questions, the referrer is clearly directed to contact SPA immediately to discuss the referral with a mental health professional. I do hope the above information is of assistance and answers the concerns raised within your Regulation 28 report following the sad death of Mr Richard Whelan. Yours sincerely Chief Operating Officer South West Yorkshire Partnership Teaching NHS Foundation Trust
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