Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0257, written 4 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 | 4 May 2026 |
|---|---|
| Reference | 2026-0257 |
| Deceased | Suseel Rana |
| Coroner | Emma Whitting |
| Coroner area | Bedfordshire and Luton |
| Source | judiciary.uk record |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
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. 2. 3. CORONER I am Emma WHITTING, Senior Coroner, for the coroner area of Bedfordshire and Luton Coroner Service. DATE OF REPORT 04 May 2026 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. 4. THIS REPORT IS BEING SENT TO 1. Chief Constable Trevor RODENHURST 2. The Rt Hon Shabana Mahmood MP You are under a duty to respond to this report within 56 days of the date of this report, namely by June 29, 2026. I, the coroner, may extend the period if an appropriate application is made. 5. 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. 6. SUMMARY OF CORONER’S CONCERN 3 As highlighted by the DARDR/SAR investigation, all relevant agencies who had contact with the Deceased had ‘worked in silo’ rather than holistically and, whilst Police responded in line with good practice to the criminal allegations made, this did not subdue the Deceased’s fear of further domestic abuse. 7. 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. 8. INVESTIGATION AND INQUEST On 24 May 2024 I commenced an investigation into the death of Suseel RANA aged 36. The investigation concluded at the end of the inquest on 15 April 2026. The conclusion of the inquest was that Suseel Rana died from Suicide. 9. CIRCUMSTANCES OF DEATH She had reported a number of domestic The Deceased suffered from a number of physical and mental health conditions whilst also being the main carer for her mother. She had been under the care of the local mental health teams since 2018 and had been diagnosed with bipolar affective disorder and generalised anxiety. She also had a history of deliberate overdose. She was being treated via the Care Programme Approach but had not been allocated a Care-Coordinator only a Mental Health Support Worker, abuse incidents since 2021 and, on 20 April 2024, her ex-partner was arrested and bailed with protective conditions following allegations that he had made threats to kill her and had caused damage at her home. Although she decided not to support the criminal investigation, on 26 April 2024, she made an application under 'Clare’s Law' in respect of that ex-partner. On 27th April 2024, she contacted the Mental Health Crisis Team stating that she was feeling overwhelmed with anxiety, suffering panic attacks, and felt unable to leave her house because her ex-partner was living nearby. She also verbalised suicidal thoughts but denied having any plans or intent to act upon them. On 2 May 2024, she again reported to her Mental Health Support Worker that she was not leaving her house on her own as she was scared about the threatening behaviour of her ex-partner and wanted to move from the area. On 13 May 2024, she was informed by the Victim Engagement Officer by telephone that there were no grounds for her 'Clare’s Law' application to be continued during which conversation she confirmed that she was struggling with her mental health. Police ensured that she was being seen by mental health services and she was reviewed by her psychiatrist that same day during which consultation she reported that 'her brain was ruminating', and she felt like she was in a ‘fight and flight’ situation, reporting both elevated anxiety and being bothered about a long-standing personal relationship. Although it was clear that she was continuing to fear becoming victim to domestic abuse, no safeguarding referral was made and opportunities for relevant statutory agencies to use the information they had to take practical steps to help her manage her anxiety, alongside her physical health issues and caring responsibilities, including using advocacy support, were not taken. She was last seen and heard from on the evening of 20 May 4 2024 and did not emerge from her bedroom on 21 May 2024. Although her mother had carers to the house that day, they did not enter her room and it was not until her friend arrived, at around 18.00 hours, be in cardiac arrest on her bedroom floor. Paramedics attended and attempted resuscitation but confirmed her death at 18.53 hours. Post-mortem examination revealed she had ingested a handwritten note found at the scene confirmed an intention to take her own life. that she was found to in excess prior to death and 10. 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: 1) In seeking some reassurance as to her safety, the Deceased had made a Clare's Law application under the Domestic Violence Disclosure Scheme (DVDS) prior to her death; however, this was had not been progressed by Police. 2) The reason for the lack of progression of the Deceased's Clare's Law application appear to have been based on a misunderstanding by the investigating officer that Clare's Law could not be used in respect of a previous partner. 3) Neither the investigating officer nor the supervising officer appeared to recognise that the Deceased's level of anxiety, as indicated by her Clare's Law application, required further safety planning. 4) The lack of progression of the Deceased's Clare's Law application to the actual decision making stage meant that the steps envisaged by the DVDS Guidance, which include a referral to a multi-agency forum (as illustrated by Figure 1 on page 8 of the Guidance), were not taken. Had such steps been taken, it is likely that the Deceased would have been more supported. 5) Whilst paragraph 76 of the DVDS Guidance states: "The police may make the decision not to progress the disclosure following the completion of intelligence checks" - it is not currently clear whether the intention of the Guidance is for Police still to proceed to the decision making stage as to whether to make any disclosure or not (which would involve the multi-agency referral referenced above) or, whether, in that situation no further steps at all are required (as occurred in respect of the Deceased's application). 11. 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] 5 CEO COLLEGE OF POLICING 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. 12. SIGNATURE Emma WHITTING Senior Coroner for Bedfordshire and Luton Coroner Service 6
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.
REGULATION 29 RESPONSE TO A REPORT ON ACTION TO PREVENT FUTURE DEATHS Please do not include any living person names in this document, in accordance with the Chief Coroner’s publication policy PDF. THIS RESPONSE IS BEING SENT TO: The Coroner, Emma WHITTING for the Coroner Area Bedfordshire and Luton Coroner Service in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following an investigation into the death of Suseel RANA, and an inquest that concluded on 15 April 2026. 1. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, Chief Constable and The Rt Hon MP provides this response within 56 days of the date of the Report to Prevent Future Deaths or any extension granted. 2. DATE OF RESPONSE 16 June 2026 3. CONFIRMATION OF CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified in the report are as follows: 1) As was highlighted by the DARDR & SAR investigations, all relevant agencies 'worked in silo' rather than holistically and, whilst police responded in line with good practice to the criminal allegations made, this did not, in fact, subdue the Deceased's fear of further domestic abuse. 2) In seeking some reassurance as to her safety, the Deceased had made a Clare's Law application under the Domestic Violence Disclosure Scheme (DVDS) prior to her death; however, this was had not been progressed by Police. 3) The reason for the lack of progression of the Deceased's Clare's Law application appear to have been based on a misunderstanding by the investigating officer that Clare's Law could not be used in respect of a previous partner. 4) Neither the investigating officer nor the supervising officer appeared to recognise that the Deceased's level of anxiety, as indicated by her Clare's Law application, required further safety planning. 5) The lack of progression of the Deceased's Clare's Law application to the actual decision making stage meant that the steps envisaged by the DVDS Guidance, which included a referral to a multi-agency forum (as illustrated by Figure 1 on page 8 of the Guidance), were not taken. Had such steps been taken, it is likely that the Deceased would have been more supported. 6) Whilst paragraph 76 of the DVDS Guidance states: "The police may make the 10 decision not to progress the disclosure following the completion of intelligence checks" - it is not currently clear whether the intention of the Guidance is for Police still to proceed to the decision making stage as to whether to make any disclosure or not (which would involve the multi-agency referral referenced above) or, whether, in that situation no further steps at all are required (as occurred in respect of the Deceased's application). 4. DETAILS OF ACTION TAKEN, how has the concern been addressed. [If no action is proposed please explain why here. If you feel that the response should not have been sent to you, please state this]. Any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. Bedfordshire Police recognise the importance of the Domestic Violence Disclosure Scheme (DVDS) and safeguarding frameworks. Whilst Bedfordshire Police maintain that the applications in this case were progressed in accordance with established policy, we recognise the Coroner’s concern and have taken steps to ensure clarity in both the understanding and articulation of the process. Concern 1 In seeking some reassurance as to her safety, the Deceased had made a Clare’s Law application under the Domestic Violence Disclosure Scheme (“DVDS”) prior to her death; however, this was had not been progressed by Police. Response The Deceased submitted two DVDS applications: • One relating to a new developing relationship • One relating to a previous partner Both applications were accepted, progressed through all relevant stages, subject to intelligence checks and reviewed at supervisory level. Each application reached formal decision-making stage, where a determination of non-disclosure was made. Both decisions were communicated to the Deceased. It is therefore not accepted that the applications were not progressed; rather, they were progressed to conclusion in accordance with policy, resulting in decisions not to disclose. 11 Concern 2 The reason for the lack of progression of the Decease’s Clare’s Law application appear to have been based on a misunderstanding by the investigating officer that Clare’s Law could not be used in respect of a previous partner. Response The DVDS applies to both current and former partners. This is clearly reflected in Bedfordshire Police policy and practice. The application regarding the former partner was progressed and assessed in line with this framework. Whilst the recording of the rationale mentioned this being a former partner, the decision not to disclose was based on: • The absence of relevant disclosable information following intelligence checks; and • Consideration of necessity and proportionality in line with DVDS guidance The DVDS requires not only the presence of information, but that disclosure is necessary and proportionate to protect the applicant from harm. Whilst the scheme applies to former relationships, the context of the relationship is a relevant factor when assessing risk and necessity. The decision reached was therefore considered and proportionate outcome, and not attributable to any misunderstanding of policy. Concern 3 Neither the investigating officer nor the supervising officer appeared to recognise that the Deceased’s level of anxiety, as indicated by her Clare’s Law application, required further safety planning. Response Bedfordshire Police recognise indicate vulnerability and requires safeguarding consideration regardless of the disclosure outcome. that a DVDS application may 12 Officers and Staff working within Domestic Abuse Investigations Teams are trained and experienced in recognising the impact of anxiety and vulnerability on victims. In this case, the Deceased was already engaged with mental health services, and two Victim Engagements Officers were in regular contact, and additional support options, including counselling referrals were provided. Officers considered the full safeguarding picture, including the existing multi- agency involvement, professional assessments and ongoing engagement with support services. The evidence demonstrates the safeguarding measures were in place, actively maintained, and supplemented where appropriate. Concern 4 The lack of progression of the Deceased’s Clare’s Law application to the actual decision making stage meant that the steps envisaged by the DVDS Guidance, which include a referral to a multi-agency forum (as illustrated by Figure 1 on page 8 of the Guidance), were not taken. Had steps been taken, it is likely that the Deceased would have been more supported. Response Both DVDS applications were progressed through established processes and subject to supervisory oversight. The case did not meet the criteria for escalation to MARAC, as it did not reach the threshold for high-risk categorisation under recognised assessment frameworks. Notwithstanding this, the Deceased was already known to and being supported by Mental Health Services and safeguarding professionals, such as Victim Engagement Officers deployed by Bedfordshire Police. As such, safeguarding was delivered within an existing multi-agency framework, even in the absence of formal MARAC referral. Concern 5 Whilst paragraph 76 of the DVDS Guidance states: “The police may make the decision not to progress the disclosure following the completion of intelligence checks” – it is not currently clear whether the intention of the Guidance is for Police still to proceed to the decision-making stage as to whether to make any disclosure or not (which would involve the multi-agency referral referenced 13 above) or, whether, in that situation no further steps at all are required (as occurred in respect of the Deceased’s application). Response Paragraph 76 of the DVDS Guidance relates to the “right to know” pathway, which differs from the “Right to Ask” process engaged in this case. Regardless of the route: • Intelligence checks are completed • A supervisory review is completed • A formal decision is recorded in all cases In this matter, these steps were followed in full. A decision of non-disclosure does not indicate a lack of progression but rather reflects completion of the DVDS process in line with guidance. 5. DETAILS OF FURTHER ACTION PROPOSED Any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. Whilst Bedfordshire Police are satisfied that relevant policy and procedures were followed in this case, we recognise the importance of maintaining and reinforcing high standards in safeguarding. We will continue to apply and embed existing guidance and established practices, ensuring that decision-making remains informed, consistent and appropriately focused on the identification and management of risk and vulnerability. This ongoing approach provides assurance that safeguarding considerations remain central to operational practice. 6. SIGNATURE 14
Minister for Safeguarding and Violence Against Women and Girls 2 Marsham Street London SW1P 4DF www.gov.uk/home-office 4 June 2026 Senior Coroner Emma Whitting DECS Reference: MIN/1508026/26 Dear Ms Whitting, Thank you for your email of 13 May to the Home Office regarding the Prevention of Future Deaths report for Ms Suseel Rana. I am replying as the Minister for Safeguarding and Violence Against Women and Girls (VAWG). Thank you for sharing a copy of this report into what was clearly a tragic case. May I first say I am so sorry to hear of the loss of Ms Rana. I can only imagine how difficult this must have been for her family and loved ones. I am sorry to hear of Ms Rana’s experience with the application she submitted to Bedfordshire Police under the Domestic Violence Disclosure Scheme (DVDS). As you know, the DVDS enables the police to disclose information to a victim or potential victim of domestic abuse about their partner’s or ex-partner’s previous abusive or violent offending. This is based on police common law powers to prevent crime. Disclosures can be made through two routes; under the ‘right to know’ route the police can proactively disclose information to protect a potential victim(s) and under the ‘right to ask’ route, a member of the public can apply directly to the police for a disclosure. Regardless of the reason for the disclosure, the safeguarding of the victim should be the priority throughout the disclosure process. At points 10(2) and 10(3) in your report you raise concerns around the way Bedfordshire Police officers handled Ms Rana’s DVDS application. I am unfortunately unable to comment on or intervene in individual cases or police investigations. This is because the police are independent of Government. However, I see that you have also shared your report with the Chief Constable for Bedfordshire Police, who I hope will be able to address these points. In your report at 10(4) you highlight “The lack of progression of the Deceased’s Clare’s Law application to the actual decision-making stage meant that the steps envisaged by the DVDS Guidance, which include a referral to a multi-agency forum, were not taken. Had such steps been taken, it is likely that the Deceased would have been more supported”. The DVDS statutory guidance indicates that it is best practice for police to refer cases to a multi-agency forum to inform disclosure decisions and advise on safeguarding measures, and that high risk applications should always be referred. However, such referrals are not mandatory and do not happen in every case. Nevertheless, the guidance recognises that in making a request, a person is often registering concerns about possible risks to their own safety. The guidance is also clear that safety planning should be undertaken for all 7 DVDS cases, be ongoing and, where appropriate, be developed in collaboration with an Independent Domestic Violence Advisor and other safeguarding agencies. As such, Ms Rana should have received appropriate safeguarding support regardless of whether her application was progressed to the decision-making stage. At 10(5) you also point out that the guidance is unclear regarding what steps police are required to take, if any, where a decision is taken not to progress a DVDS case to the decision-making stage. This is an important point; thank you for bringing it to my attention. I am aware that there are issues and inconsistencies in the way that the DVDS is currently being implemented across forces in England and Wales, and that more needs to be done to make sure the current scheme is working well for victims. In the VAWG Strategy, the Home Office committed to working closely with the National Centre for VAWG and Public Protection and the Independent Office for Police Conduct to create a clearer, more consistent framework for police and other agencies to improve implementation of the DVDS. The Home Office also committed to explore the potential to expand the DVDS to other forms of VAWG. I would like to assure you this work to improve disclosure schemes is underway, and I will ensure that the issues you have raised are considered as part of it. The Home Office is also working to develop and roll out a digital tool to support the police to make better decisions when disclosing information. The scale of VAWG is a national emergency and a top priority for this Government, and we are working to deliver a cross- government transformative approach to halve VAWG in a decade, underpinned by the new VAWG Strategy. Protecting victims is also a top priority for me personally, and I hope this response assures you that I am committed to improving the DVDS and ensuring victims are properly safeguarded by police. Thank you once again for sharing your report with the Home Office. Yours sincerely, Minister for Safeguarding and Violence Against Women and Girls 8
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