Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0255, written 13 May 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 May 2026 |
|---|---|
| Reference | 2026-0255 |
| Deceased | Nigel Keenan |
| Coroner | Robert Cohen |
| Coroner area | Cumbria |
| Source | judiciary.uk record |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Miss K J Gomersal LLB | Senior Coroner | Cumbria
HM Coroner's Courts, Allerdale House, Workington, Cumbria CA14 3YJ
13 May 2026
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: NHS England
1) CORONER
I am Mr Robert Cohen, HM Assistant Coroner for Cumbria
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3) INVESTIGATION and INQUEST
On 21 March 2025 an investigation commenced into the death of Nigel John KEENAN. The
investigation concluded at the end of the inquest . The conclusion of the inquest was
Suicide
1a Hanging
1b
1c
II
4) CIRCUMSTANCES OF THE DEATH
The jury's findings in respect of Mr Keenan's death were as follows:
Death by hanging
at HMP Haverigg. At a time between 8 pm on 12th March 2025 and the time of being found:
3:15 am 13th of March 2025. Time of death officially recorded by North West ambulance
service: 4:20 am 13th of March 2025
As John's release date approached issues arose regarding his life after prison and how
restrictions imposed due to the nature of his offence could impact this. Finding suitable
housing was proving problematic. Only eight days prior to release John was finally notified
that he would be able to reside with a family member. However it is probable that the
heightened stress and worry of this matter contributed more than minimally to his death.
Other possible contributing factors to the stress and anxiety John was facing at this time was
a recent relationship breakdown and financial worries.
The week before John's death intelligence suggested John was planning to do something
that would shock the prison.
Prison staff interpreted this as John being a risk of absconding. John had mentioned, a month
earlier, that he was experiencing suicidal thoughts. However after following this up with
healthcare providers he was not deemed a risk.
When questioned John denied making the comment. Given the prior mention of suicidal
thoughts and then the threat of doing something to shock the prison, a simple questioning of
whether he said this with no further exploration could have been a missed opportunity.
However HMP Haverigg have demonstrated they have multiple avenues of support available
some of which John chose not to engage with.
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. –
In the course of hearing evidence in this inquest I was told that: 1) Mental health provision is
only commissioned within HMP Haverigg during the week and is not available at the
weekends. I was told that in the event that a prisoner experienced crisis during the weekend
they would be cared for by prison staff using the ACCT procedure, but that mental health
input would not be available until Monday morning. 2) Because HMP Haverigg is a Category
D 'open' prison it has far fewer staff available to monitor prisoners. As such it is not able to
place prisoners on 'constant watch'. As a result if a prisoner requires very regular or constant
observation (as a result of being in crisis) they would have to be transferred to a closed
prison. 3) This means that prisoners who are in crisis have something of an incentive to deny
their intent to self harm because to admit to it would result in their being transferred to a
closed prison.
I am concerned that the decision not to commission 7 day a week mental health support at
HMP Haverigg is therefore counterproductive. Because of the limited number of prison
officers at the establishment it gives rise to a higher risk than wiould be the case at a closed
prison. In particular, it risks providing an incentive for prisoners in crisis to play down the true
extent of their situation.
6) ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe that, as
healthcare in prisons is directly commissioned, NHS England 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 8th July 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 Interested Parties.
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.
13 May 2026
Signature
Robert Cohen HM Assistant Coroner for
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 Robert Cohen
HM Assistant Coroner for Cumbria
HM Coroner’s Office
Fairfield
Station Road
Cockermouth
Cumbria
CA13 9PT
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
22nd June 2026
Dear Mr Cohen,
Re: Regulation 28 Report to Prevent Future Deaths – Nigel John Keenan who
died on 13th March 2025.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 13th
May 2026 concerning the death of Nigel John Keenan on 13th March 2025. In advance
of responding to the specific concerns raised in your Report, I would like to express
my deep condolences to Nigel’s family and loved ones. NHS England is keen to assure
the family and yourself that the concerns raised about Nigel’s care have been listened
to and reflected upon.
Your Report raised the following concerns:
1. Mental health provision is only commissioned within HMP Haverigg during the
week and is not available at the weekends.
2. Category D 'open' prisons do not allow for very regular or constant observation
when required, meaning prisoners have to be transferred to a closed prison for
these observations. You were concerned this may mean prisoners in crisis deny
their intent to self-harm to avoid being transferred.
With regards to overnight staffing levels and the lack of clinical presence overnight,
outside of weekday hours; the commissioning and provision of healthcare services
across the England prison estate is based on a national service specification and
health needs assessment for each establishment. It is overseen by the NHS England
regional health and justice commissioning team.
HMP Haveriggg is a Category D establishment, which means it is considered as
someone’s ‘usual residence’, or home. There is therefore no provision for overnight
healthcare. The national service specification details the need for access to community
out of hours service for any concerns that need to be assessed and treated out of
prison healthcare hours.
A review of the NHS England national health and justice service specifications is
currently underway, with a view to finalising this in Summer 2026, and any learning
from this case will be used to ensure that the primary care specification continues to
support commissioners to be able to tailor services to meet the needs of their prison
population. They ensure providers are clear on core service delivery and standards
they are expected to prioritise which includes access to Out of Office Hours services.
Delivery of
the responsibility of regionally regional
commissioners under contract management processes
these specifications
is
Regional Response
NHS England has liaised with the NHS England’s North West Region Health & Justice
team regarding your Report. They have advised that there is a 7-day service at HMP
Haverigg. The hours are 8am-6pm Monday to Friday and 8am – 4.30pm Saturday and
Sunday. The provider operates an ‘on call’ service over the weekend, with a core
service delivering Monday to Friday, following a review of engagement over the
weekends and prisoners reporting a preference for appointments during the week.
Practitioners are contactable via an on-call number and will attend the prison to see
anyone who requires assessment or intervention. There have been some issues with
communicating this to the primary care provider and this has been rectified.
Further communications and meetings have occurred with HM Prison and Probation
Service (HMPPS) to outline the offer and this has been agreed. The North West
Health & Justice will review the provision over the next 6 months, looking at need and
demand for weekend on site presence.
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 Nigel,
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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