Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0239, 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 report | 30 Mar 2026 |
|---|---|
| Reference | 2026-0239 |
| Deceased | Moira Parker |
| Coroner | Bina Patel |
| Coroner area | Bedfordshire and Luton |
| Source | judiciary.uk record |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
PREVENTION OF FUTURE DEATHS REPORTS PUBLICATION POLICY Introduction 1. If during an investigation, a coroner becomes concerned about circumstances that create a risk of future deaths, Paragraph 7 of Schedule 5, Coroners and Justice Act 2009, provides coroners with the duty to make reports to a person, organisation, local authority or government department or agency where the coroner believes that action should be taken to prevent future deaths. That report is called a Prevention of Future Deaths Report (PFD report). 2. Anyone to whom a PFD report is directed must send the coroner a response. The reports and responses must be sent by the coroner to the Chief Coroner. 3. Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 (the Regulations) set out the procedures that apply to PFD reports and responses. 4. This policy explains the Chief Coroner’s approach to the publication and redaction of PFD reports and responses, and the process for raising concerns in a particular case. 5. This policy may be amended from time to time. Any amendments will be published on www.judiciary.uk. Publication 6. The decision to issue a PFD report is a judicial one. To comply with the principle of open justice, the public must be able to access PFD reports and responses, unless there is a compelling reason to restrict access. The scrutiny of PFD reports and responses is also vitally important to society, to enable themes to be recognised, any necessary systemic changes to be put in place, and any promises of change to be enforced. There is therefore a presumption that PFD reports and responses will be published by the Chief Coroner. 7. Published PFD reports and responses can be accessed via the following link: Reports to Prevent Future Deaths | Courts and Tribunals Judiciary, and can be filtered by subject and/or date. Since 1 January 2023, all PFD reports have been 1 published directly onto a webpage, which means that the full text of those reports is searchable. 8. The Chief Coroner recognises that the internet has made information easily and widely accessible, and that there must be a balance between openness, and the need to respect individuals’ privacy and protect the public from harm. Some PFD reports and responses will therefore be redacted prior to publication. In exceptional cases, the Chief Coroner may decide against publication in any form. 9. The Chief Coroner’s power to publish PFD reports and responses does not affect the power of individual coroners to provide copies of PFD reports and responses in accordance with Regulation 27 of the Regulations. Anyone who wishes to obtain a copy of a PFD report or response in its original form can apply to the coroner area that issued the PFD, and the coroner will consider that request. Approach to redaction 10. The following information will usually be redacted from PFD reports and responses prior to publication by the Chief Coroner, to remove information on how death can be caused, and to protect the privacy of individuals: a) Any names, initials and signatures of individuals, except for those of the deceased; b) Email addresses of individuals; c) Personal address details; d) Direct telephone numbers of individuals; e) Case reference numbers; and f) Information that is not commonly known that could help someone to cause a death, including: i) ii) iii) iv) the name of novel products or substances that were used to cause a death, information on how such products or substances were obtained; the amount of any substance that caused a death; the mechanism used to cause a self-inflicted death (for example, information on how a ligature was created); v) websites that were used to plan a death; vi) vii) the locations of suicide spots; details of how any secure areas used for suicide were accessed. 11. Other information may also be redacted if the Chief Coroner considers that redaction to be in the public interest and/or necessary to protect specific individuals. 12. The Chief Coroner may decide not to make a particular redaction if it is considered that it would significantly inhibit the public's understanding of the learning in a report or response. 2 13. Any links to webpages included in responses will not be checked for sensitive information prior to publication, as the information is already online. In the event that sensitive information can be obtained by clicking an embedded link in a report or response (for example, because being associated with a report affects the anonymity of a linked document), representations about publication of the link should be made when the response is submitted. Decision not to publish 14. If the Chief Coroner decides that the redactions needed to protect the public and/or particular individuals would prevent a PFD report or response from being understood, or that redaction of the document could not sufficiently mitigate any public or individual risk, the Chief Coroner may decide not to publish a report or response. 15. If the Chief Coroner decides not to publish a document, the following will apply: a. If the document is a PFD report, the Chief Coroner will instead publish a brief note about the topic of the report, together with confirmation that a copy of the report can be requested from the relevant coroner area. b. If the document is a response, the Chief Coroner will instead publish a statement that the response has not been published but can be requested from the relevant coroner area. 16. Individuals and organisations responding to PFD reports occasionally try to use the publication of a response as a way to challenge publicly the validity of the coroner’s decision to issue a PFD report. This is not appropriate. Coroners’ decisions can be challenged in the courts, but unless they are successfully challenged, they should be respected. The Chief Coroner will not allow her publication power to be used as an unofficial method of challenging coroners’ decisions. If a response adopts this approach, the coroner who issued the PFD report will deal with the response in the usual way, including providing a copy to interested persons (IPs), and considering disclosure requests from the public in accordance with Regulation 27 of the Regulations. However, the Chief Coroner may decide not to publish the response. Representations about publication 17. The IPs, any organisation or person to whom a PFD report is directed, and anyone who considers their right to private and family life is affected by the content of a report or response, may make representations about: a) the decision to publish; b) whether redactions are needed; 3 c) any specific redactions requested; and d) any other matter that may be relevant to the Chief Coroner’s publication decision. 18. Before making such representations, the following points should be noted: a) The Chief Coroner will not consider representations about whether a PFD report ought to have been issued, or what information it should have included. Coroners are independent judicial office holders, and the Chief Coroner cannot interfere with their decisions. Representations will only be considered by the Chief Coroner if they relate to the publication of PFD reports or responses; b) All representations should include clear details of what the Chief Coroner is being asked to do and the reasons why that action is thought to be necessary; and c) As there is a presumption that PFD reports and responses will be published, anyone making representations about publication should consider whether a decision not to publish is proportionate, or whether publication in a redacted form would be sufficient to alleviate their concerns. 19. A person or organisation providing a response to a PFD report should send any representations regarding publication to the coroner who made the report. These representations should be made at the same time as the response is provided. The coroner will pass any representations to the Chief Coroner. 20. Any person who is not responding to a PFD report but who wishes to make representations regarding publication of a report or response before that document is published should also send their representations to the coroner who made the report. Those representations should be sent within 56 days (unless the coroner grants an extension) and will be sent by the coroner to the Chief Coroner at the same time as the responses. 21. After a report or response has been published, or the Chief Coroner has confirmed that a report or response will not be published, any representations about the publication decision can be sent to the Chief Coroner directly. The relevant email address is: chiefcoronersoffice@judiciary.uk. Timing of publication 22. PFD reports and responses will be compiled by the coroner that made the report and sent to the Chief Coroner as a package, together with any representations about publication. 23. If at the end of the 56-day time limit (plus any extension granted by the coroner, whether for a response or for representations to be made about publication), the coroner has not received all of the expected documents, the coroner will send the 4 PFD report, and any responses and representations that have been forthcoming, to the Chief Coroner. The Chief Coroner will then proceed with publishing those documents that are available (or publishing a statement about non-publication, if appropriate). 24. The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages (link: Non-responses to Prevention of Future Death (PFD) reports - Courts and Tribunals Judiciary). 25. When representations are received by the Chief Coroner after publication has already taken place, the documents will usually remain on the website until the Chief Coroner has considered the representations. If the Chief Coroner decides to remove or amend the documents, the changes will be made as soon as is reasonably practicable. 26. When making publication decisions following representations made in accordance with this policy, the Chief Coroner will consider the following factors: a) The need for open justice; b) The importance of the information to the public interest; c) The right of any relevant individual to respect for their private and family life under Article 8 of the European Convention of Human Rights; and d) The harm that might be caused by publication of the information. HHJ ALEXIA DURRAN CHIEF CORONER April 2026 5
REPORT TO PREVENT FUTURE DEATHS REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 If during an investigation, a coroner becomes concerned about circumstances that create a risk of future deaths, Paragraph 7 of Schedule 5, Coroners and Justice Act 2009, provides coroners with the duty to make reports to a person, organisation, local authority or government department or agency where the coroner believes that action should be taken to prevent future deaths. That report is called a Prevention of Future Deaths Report (PFD report). The Chief Coroner provides this template to support coroners in the effective and consistent exercise of their statutory duties under the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. The purpose of the template is to provide a clear and structured framework for setting out the matters of concern identified during an investigation which, in the coroner’s opinion, give rise to a risk of future deaths. It is designed to promote clarity, ensure that reports are formulated in a way that enables recipients to understand and address the concerns raised, and to support good practice across jurisdictions. The template does not fetter judicial independence: coroners remain responsible for determining the facts, identifying the matters of concern, and drafting reports that accurately reflect the circumstances of each individual case. The template may be adapted as necessary to ensure that the report properly and precisely records the coroner’s views. In accordance with the Chief Coroner’s PFD Publication Policy (2026) any applications for redactions to content or general publication of the report must be sent to the coroner. The coroner will provide the representations to the Chief Coroner for a decision. REPORT TO PREVENT FUTURE DEATHS REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 Please do not include any living persons’ names in this document, in accordance with the Chief Coroner’s PFD Publication Policy (2026). 1. CORONER I am Bina Patel, Area Coroner, for the coroner area of Bedfordshire & Luton. 2. DATE OF REPORT 30 April 2026 3. 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. THIS REPORT IS BEING SENT TO 1. Unilever PLC 2. 3. You are under a duty to respond to this report within 56 days of the date of this report, namely by 25 June 2026. I, the coroner, may extend the period if an appropriate application is made. 4. YOUR RESPONSE 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. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports - Courts and Tribunals Judiciary. 5. SUMMARY OF CORONER’S CONCERN From the contents of the letters left by Moira and the evidence heard at the inquest, Moira raised concerns over a protracted period of time from July 2022 to October 2024 and a referral was not made to occupational health which would have triggered the use of the stress risk assessment and provided support both for Moira and those within the management team. 6. ACTION SHOULD BE TAKEN In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe you have the power to take such action. 7. INVESTIGATION AND INQUEST On 22 April 2025, I commenced an investigation into the death of Moira Diane Parker, aged 54 years. This inquest was concluded on the 18 March 2026. The medical cause of death was 1 a Fatal Haemorrhage and Haemothorax 1 b Stab Wounds to Neck and Wrist How, when and where On 11 April 2025 Moira was found at Priory Marina River Bank, Barkers Lane, Bedford with stab wounds that were self-inflicted in the neck and wrist. Conclusion Suicide - The Deceased intentionally took her own life following a deterioration in her mental health after a decline in her cognitive function. 8. CIRCUMSTANCES OF DEATH The Deceased, a Microbiologist, had worked for Unilever for thirty-six years in research and Development (“R&D”), which was a job she loved. She had struggled with mental and physical health issues for several years, which included a decline in her memory and cognitive function. These were being investigated by her GP through scans and blood tests. She was placed on Hormone Replacement Therapy to assist with her symptoms thought to be linked with menopause and although she reported some initial improvement when she commenced therapy, her underlying memory and brain function issues continued to exist since October 2022. Subsequently, she found herself under increasing pressure at work. She raised issues about her workload and an increase in her working hours that included weekends, during meetings with her line manager in December 2022, March 2023 and in October 2024 when she said she reported that was struggling to keep up with workload. A marked change in her demeanour was noticed by management in January 2025 where she appeared withdrawn and anxious. On the 5 February 2025 she contacted her GP through an eConsult reporting an escalation of her memory issues, panic attacks and feelings of being unable to cope, burnt out, the following day she certified herself sick from work. Although she was open about her health issues and work-related pressures, an occupational health referral was not made by management until 14 February 2025, after she went on sick leave. Following this, she had an appointment with her GP on the 20 February 2025 where she discussed her symptoms and there was an exploration of possible physical and psychological causes. A subsequent CT scan revealed no physical abnormalities, but her bloods identified low folate and subclinical hypothyroidism and medication was prescribed. A referral was also made to the Memory Assessment Service for further investigation for her ongoing symptoms. She was under the care of the Memory Assessment Service from the 12 March 2025 to the 27 March 2025, on the afternoon of the 11 April 2025 she was found at Priory Marina River Bank, Barkers Lane, Bedford with stab wounds that were self-inflicted in the neck and wrist. Emergency Services attended but her death was confirmed by paramedics at 13:40 hours. She had last been seen at 07:30 hours that morning when she had left her home informing her husband, she was attending her GP surgery to collect a fit note for work. Notes were left. 9. CORONER’S CONCERNS During the course of the inquest I heard evidence 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: From the contents of the letters left by Moira and the evidence heard at the inquest, Moira raised concerns over a protracted period of time from July 2022 to October 2024 and a referral was not made to occupational health which would have triggered the use of the stress risk assessment and provided support both for Moira and those within the management team at Unilever, I am not satisfied staff have sufficient knowledge and training about the circumstances in which an occupational health referral can be made and the support that is available. 10. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: [please do not use individual’s names, but instead roles/titles] 1. The family of Moira Parker 2. Unilever PLC 3. Zello UK Limited (Occupational Health) 4. GP Partner & GPs at Goldington Avenue Surgery I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. SIGNATURE
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