Prevention of Future Deaths reports · 2026

Suseel Rana

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 report4 May 2026
Reference2026-0257
DeceasedSuseel Rana
CoronerEmma Whitting
Coroner areaBedfordshire and Luton
Sourcejudiciary.uk record
Responses published2

The report

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

Responses

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.

Response from Bedfordshire Police
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
Response from Home Office
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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