Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0256, written 7 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 | 7 May 2026 |
|---|---|
| Reference | 2026-0256 |
| Deceased | Alan Whelan |
| Coroner | Oliver Longstaff |
| Coroner area | West Yorkshire (East) |
| Source | judiciary.uk record |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
OFFICE OF THE ACTING SENIOR CORONER for the County of West Yorkshire (Eastern District) His Majesty’s Coroner’s Office The Coroner’s Courts Burgage Square Wakefield WF1 2TS 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 Oliver Longstaff, Acting Senior Coroner for the West Yorkshire (Eastern) coroner area. 2. DATE OF REPORT 07/05/2026 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. The Ministry of Justice 2. Practice Plus Group You are under a duty to respond to this report within 56 days of the date of this report, namely by 03/07/2026. 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 A serving prisoner in HMP Leeds, who was on an open ACCT document, was moved to the Segregation Unit in the prison after starting a fire in his cell shortly before 1500 hrs on 24/12/2024. Pursuant to PS 1700 he should have had a mental health assessment within 24 hours of his arrival in the Segregation Unit. No such assessment took place. Shortly before 2330 hrs on 25/12/2024, he was found hanging in his cell on the Segregation Unit and transferred to hospital, where he died on 30/12/2024. 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 each of you have the power to take such action. 7. INVESTIGATION AND INQUEST On 08/01/2025, I commenced an investigation into the death of Alan Joseph Whelan, aged 41 years… The medical cause of death was 1a) Hypoxic Encephalopathy; b) Hanging The deceased died on 30/12/2024 in Leeds General Infirmary, where he had been brought on 25/12/2024 from HMP Leeds, where he had been found hanging in his single-occupancy cell on the Segregation Unit. Conclusion (Jury’s narrative conclusion) Alan Joseph Whelan was found ligatured in his cell on 25th Dec 2024 and subsequently died on 30th December 2024 at Leeds General Infirmary. It is possible that loss of work was a trigger to Alan’s mental state and thought process. Following previous incidents, we feel that observations should have been made more regularly, and any ACCT reviews should have considered previous incidents. It cannot be established that Alan not being more frequently observed probably contributed to his death, but it is possible that it did so. Admission by MoJ The prison officer conducting ACCT observations on Alan on the night of 25th Dec did not comply with the requirement to conduct one check at irregular intervals every 60 minutes. By the time he conducted the check which led to Alan’s discovery it had been 1 hour and 11 minutes since the last check. It cannot be established that this finding probably contributed to the death, but (it) may have done so. 8. CIRCUMSTANCES OF DEATH Alan Whelan, a serving prisoner in HMP Leeds who was on an open ACCT document, was moved to the Segregation Unit in the prison after starting a fire in his cell shortly before 1500 hrs on 24/12/2024. Pursuant to PS 1700 he should have had a mental health assessment within 24 hours of his arrival in the Segregation Unit. No such assessment took place. An ACCT review attended by a mental health practitioner was held on the morning of 25/12/2024, but that practitioner gave evidence that an ACCT review was not an appropriate substitute for a 1:1 mental health assessment. The evidence at inquest did not establish whether the failure to conduct a mental health assessment as required by PS 1700 was an oversight or a deliberate decision, to which the resources available in the prison on Christmas Day may have contributed. Shortly before 2330 hrs on 25/12/2024, Alan was found hanging in his cell on the Segregation Unit and transferred to hospital, where he died on 30/12/2024. 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: A mandatory requirement that a prisoner on an open ACCT document should have a mental health assessment within 24 hours of being transferred to the Segregation Unit was not complied with. Alan took steps that caused his death after that 24-hour window had closed. There was scant acknowledgment of this breach of a standing instruction from the witnesses who gave evidence to the inquest. The possibility that not carrying out such an assessment made no difference to the outcome is obvious. But that possibility neither explains nor excuses the failure to comply with the instruction, especially where it is unclear whether that failure was inadvertent or deliberate, and if deliberate, with what justification. 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: 1. Alan Whelan’s family’s legal representatives 2. The Ministry of Justice 3. Practice Plus Group 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 DATE 07 May 2026
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.
Director General of Operations HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ 2 July 2026 Oliver Longstaff Acting Senior Coroner for West Yorkshire (E) His Majesty’s Coroner’s Office The Coroner’s Court Burgage Square Wakefield WF1 2TS Dear Mr Longstaff, Thank you for your Regulation 28 report of 7 May 2026 following the inquest into the death of Alan Whelan at HMP Leeds. I am responding as Interim Director General of Prisons on behalf of the Ministry of Justice. I know that you will share a copy of this response with Mr Whelan’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority. Following evidence heard at the inquest you raised a concern regarding the requirements for mental health assessments for prisoners held in segregation unit whilst being managed under ACCT procedures. I understand that Practice Plus Group will be responding to this matter separately. HMPPS remains fully committed to ensuring the safety and wellbeing of all individuals in its care. Where a prisoner is being managed through the ACCT process, placement in segregation will only occur in exceptional circumstances and with appropriate safeguards in place. The current segregation policy (PSO 1700) sets out the requirements for managing those subject to ACCT. NHS England service specifications require healthcare providers to meet all obligations, responsibilities and requirements for healthcare input as stated in relevant HMPPS policies, with prison Governors required to ensure delivery of healthcare services is facilitated within the establishment. Governors work collaboratively with providers when new healthcare contracts are commissioned and implemented to ensure staff are informed and equipped to meet their responsibilities within the HMPPS operational environment. A comprehensive review of the segregation policy is currently underway, with publication of the revised framework scheduled for later this year. As part of this work, the Segregation Policy Framework has been aligned with the Safety Policy Framework to reduce duplication, improve clarity and strengthen consistency across related provisions, including healthcare. Under the Safety Policy Framework an ACCT case review must take place within 24 hours of a prisoner being placed in segregation conditions. Healthcare and/or mental health staff are required to attend the initial case review. In exceptional circumstances, where attendance is not possible, a verbal or written contribution must be provided to ensure appropriate clinical input informs decision making . The updated Segregation Policy Framework will be published alongside a comprehensive suite of supporting tools and learning resources designed to support effective implementation within prisons and ensure staff are aware of the expectations. In addition, HMPPS will deliver a structured programme of scheduled briefing sessions, providing staff - including healthcare professionals- with the opportunity to familiarise themselves with the revised policy, and receive guidance on its application in practice. I hope the measures outlined above provide you with reassurance that learning has been taken from the circumstances of Mr Whelan’s death and that the matters of concern that you identified have been addressed. Yours sincerely Interim Director General Prisons
OFFICE OF THE ACTING SENIOR CORONER for the County of West Yorkshire (Eastern District) His Majesty’s Coroner’s Office The Coroner’s Courts Burgage Square Wakefield WF1 2TS RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS REGULATION 29 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). THIS RESPONSE IS BEING SENT TO: HM Acting Senior Coroner, Mr Oliver Longstaff, for the Coroner Area West Yorkshire (Eastern) in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following an inquest into the death of Alan Joseph WHELAN that concluded on 20/03/2026. RESPONDENT 1. In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, The Ministry of Justice and The Practice Plus Group provide this response within 56 days (plus any extension granted) of the date of the Report to Prevent Future Deaths. DATE OF RESPONSE 2. 03/07/2026 CONFIRMATION OF CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified in the report are as follows: 3. A mandatory requirement that a prisoner on an open ACCT document should have a mental health assessment within 24 hours of being transferred to the Segregation Unit was not complied with. Alan took steps that caused his death after that 24-hour window had closed. There was scant acknowledgment of this breach of a standing instruction from the witnesses who gave evidence to the inquest. The possibility that not carrying out such an assessment made no difference to the outcome is obvious. But that possibility neither explains nor excuses the failure to comply with the instruction, especially where it is unclear whether that failure was inadvertent or deliberate, and if deliberate, with what justification. DETAILS OF ACTION TAKEN, how has the concern been addressed. [If no action is proposed please explain why here]. 4. Please note that any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. Practice Plus Group (“PPG”) would like to clarify that the document PS1700, referred to in the Regulation 28 report dated 7 May 2026, is a HMPPS policy and is not under the control of PPG. Practice Plus Group has both its own national policy and local policies in place to address the issue of providing healthcare in segregation. PPG will therefore respond to the Coroner’s concern to which it relates to healthcare only. In respect of PPG’s staff’s knowledge of the relevant provision within PSO1700, following receipt of the Coroner’s Regulation 28 response, both PPG’s National Mental Health & Psychosocial Lead and its Medical Director for Health in Justice (HiJ) have reviewed PPG’s HiJ mental health policies. PPG acknowledge that its policies do not contain an explicit requirement that matches PSO1700, i.e. that: “a mental health assessment must be undertaken by Healthcare/Mental Health In-Reach staff of all prisoners on an open ACCT (or in the post-closure phase of ACCT) who are placed in a segregation unit or awarded a period of cellular confinement in another part of the establishment. This must take place within 24 hours.” PPG’s national HiJ mental health policy is due to be revised at the end of 2026 and PPG will ensure that this issue is specifically addressed in the revised mental health policy, to ensure alignment with PSO1700. In the meantime, communication has been sent to PPG’s HiJ regional managers and regional mental health leads highlighting the requirement within PSO1700 and requesting that this is consistently implemented across all of our services. The role of PPG’s regional managers and regional mental health leads is to implement, communicate and embed processes and ensure compliance with the same. DETAILS OF FURTHER ACTION PROPOSED Please note that any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. 5. As detailed above, the issue will be addressed in PPG’s updated mental health policy which is due to be published at the end of 2026. In addition, PPG will be working with HMPPS both at site level and nationally to ensure effective communications are in place between the two organisations to make sure patients who are on ACCTs and then moved to segregation are identified, Further, PPG has a mental health steering group, which meets quarterly, and is attended by all regional mental leads, the National Mental Health & Psychosocial Lead, the Lead Psychiatrist and the Lead Psychologist. On the agenda at the next meeting, due to take place in July 2026, is obtaining confirmation that the aforementioned communication has been actioned at site levels and confirmation that compliance is being monitored at a regional level. PPG already has a process in place, within its audit schedule, to audit ACCTs, which is called Take ACCTion. It is intended that the Take ACCTion audit will be updated to include whether there has been compliance with PSO1700, to check if a mental health assessment has taken place. This will occur at the end of 2026, to align with the publication of the updated mental health policy. SIGNATURE , Medical Director Health in Justice, Practice Plus Group DATE 23/6/2026
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