Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0245, written 29 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 | 29 Apr 2026 |
|---|---|
| Reference | 2026-0245 |
| Deceased | REDACTED |
| Coroner | James Bennett |
| Coroner area | Birmingham and Solihull |
| Source | judiciary.uk record |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
1 2 3 4 OFFICIAL REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: NHS England. CORONER I am James Bennett Assistant Coroner for Birmingham and Solihull. 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. INVESTIGATION and INQUEST On 21 October 2025 I commenced an investigation into the death of . The investigation concluded at the end of the inquest on 2 April 2026. CIRCUMSTANCES OF THE DEATH had no known mental ill-health and was an experienced Operational Department Practitioner based at Birmingham Children's Hospital. During his shift on 07/10/25 he was informed of a conduct issue. A risk assessment noted he could travel home safely and having family at home was a supportive factor. He was informed he should not come into work the following day whilst a decision was made about an investigation, and that he would be telephoned the following morning with an update. The following morning, on 08/10 around 5:30-6:00am, contrary to instructions, he attended the hospital and accessed a secure drug store and removed anaesthetic medication and intravenous cannula equipment. This was the last known sighting. From 8:45am his employer attempted to contact him via telephone without success to inform him he was to be suspended pending an investigation. Concerns were escalated around 1:30pm that he was a missing person. When it was revealed he had accessed the hospital, a search was undertaken and he was found in the afternoon deceased in a bedroom in on-call accommodation having deliberately injected himself with the anaesthetic. The medical cause of death was confirmed at post-mortem as 1a. Self-injection of . The conclusion was that death was the consequence of suicide. 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 will 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. The Trust level investigation identified concerns that NHS England guidance - e.g. (a) NHS England Misconduct Policy ‘Every organisation has a duty of care to protect its employees from and prevent incidents of sexual misconduct’; and (b) e-learning ‘Understanding Sexual Misconduct in the Workplace’ – omits to deal with how to discuss and manage the alleged perpetrator when a member of staff. It does not cover when the Trust may need to conduct a risk assessment of the likely impact on the staff member of being confronted with a serious allegation, when they may need to inform the police promptly, or advise on what factors impact the need for a prompt decision on suspension and withdrawal of easy access to fatal drugs. Since this incident the local Trust has updated their policies so that a same day decision is made on these matters and in a similar incident in the future it is likely the staff member would have been immediately suspended and had their access to fatal drugs removed. My concern is that NHS England guidance continues to omit such considerations and at a local level Trusts are not fully assessing the risks. OFFICIAL OFFICIAL 6 7 8 9 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 24 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. Family of 2. Birmingham Women’s and Children’s NHS Foundation Trust. . The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she 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. 29 April 2026 Signature: James Bennett Assistant Coroner for Birmingham and Solihull OFFICIAL
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.
Mr James Bennett
Assistant Coroner
Birmingham and Solihull
The Birmingham and Solihull Coroner’s Court
Steelhouse Lane
Birmingham
B4 6BJ
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
8 June 2026
Dear Mr Bennett,
Re: Regulation 28 Report to Prevent Future Deaths –
who died on 8 October 2025.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 29 April
2026 concerning the death of
on 8 October 2025. In advance
of responding to the specific concerns raised in your Report, I would like to express
family and loved ones. NHS England is keen to
my deep condolences to
care have been
assure the family and yourself that the concerns raised about
listened to and reflected upon.
NHS England takes the sexual safety of staff and patients very seriously and we have
produced a comprehensive suite of documents to ensure that NHS employers are
taking their legal responsibilities around sexual harassment prevention seriously.
These include:
• The Sexual Safety Charter – an aspirational set of principles that all NHS trusts
and ICBs have signed up to;
• The national sexual misconduct policy framework – an adaptable framework for
trusts and ICBs to use to develop their own local sexual misconduct policies;
• Understanding sexual misconduct in the workplace – base level training for all
employees to be aware of issues surrounding sexual misconduct, disclosures
and appropriate behaviours.
Your Report raised concerns about whether these documents are clear enough about
how to support employees who are perpetrators or alleged perpetrators of sexual
harassment in the NHS.
We take support for all those involved in these processes very seriously.
Organisational support for these individuals is contained within the national policy
framework which makes clear that support should be provided to all involved. This is
done in several places within the framework:
• Under the review group section of the policy framework, it is recommended that
organisations set up review groups for specially reviewing any case with a
sexual component. In this section, we make clear that a risk assessment should
be done for all those involved which should include assessment of possible
harm and where police should be contacted.
• The associated review group checklist is clear that support should be offered
to all those involved and a risk assessment should be contact to support
wellbeing and to reduce any further harm.
• The responsibilities for HR teams includes making clear that HR should offer
support to everyone involved in a report.
The national sexual misconduct policy framework makes clear that risks to individuals
should be immediately assessed and steps should be taken once an allegation is
reported. Steps such as suspension or removing access to fatal drugs should be
considered, but these actions would not be governed specifically by a sexual
misconduct policy. These decisions would typically be governed by policies relating to
managing conduct (disciplinary), competence, professional standards regulations or
medications management.
NHS England are also taking further steps to ensure that harm arising from going
through the process of an employee relations case is mitigated. We are currently
reviewing the investigations training offered to every trust HR team in the country,
which has a significant focus on sexual misconduct clear sections on how to reduce
harm from these processes for all parties. We are also developing a national conduct
and competence policy framework which will have key sections on planning support
for those involved in the process and risk assessment.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors, and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of
, are shared across the NHS at both a national and regional level and helps us
to pay close attention to any emerging trends that may require further review and
action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
NHS England
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