Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0258, written 8 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 | 8 May 2026 |
|---|---|
| Reference | 2026-0258 |
| Deceased | Shay Middleton-Pierce |
| Coroner | Anna Loxton |
| Coroner area | Surrey |
| Source | judiciary.uk record |
| Responses published | 1 |
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. CORONER I am Anna Loxton, Assistant Coroner, for the coroner area of Surrey. 2. DATE OF REPORT 8th May 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. 4. THIS REPORT IS BEING SENT TO 1.Chief Constable, British Transport Police You are under a duty to respond to this report within 56 days of the date of this report, namely by Monday 6th July 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 Please see Box 10 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 14th April 2025 Simon Wickens, Area Coroner, commenced an investigation into the death of SHAY MIDDLETON-PIERCE (aged 15). The investigation concluded at the end of a 9-day inquest before a jury on 19th March 2026. The Jury recorded a Narrative Conclusion. Within this, the Jury recorded that Shay died due to “multiple traumatic injuries as a result of suicide on 29th March 2025 at Railway track near to Nutfield train line crossing, Redhill, Surrey”. They also recorded the following: “Based on Shay’s Snapmaps location which indicated London Bridge area, British Transport Police (BTP) were informed of Shay’s possible location and suicidal ideation. BTP graded it as 1 requiring immediate action. BTP deployed a police unit to London Bridge Station but based on the timeline of events Shay was now on a train back towards Redhill. The BTP staff identified the possible train Shay was on and when he may reach Redhill Station also based on Snapmaps update. BTP failed to establish if officers could have been deployed to Redhill Station to meet the train in time. BTP failed to update Surrey Police that they were not attending Redhill Station when the log was moved from the dispatch queue to the sub queue at 14.13 in error.” The Jury recorded the following finding in relation to the death as a possible contribution to Shay’s death: “There was a failure by British Transport Police to update Surrey Police that they were not attending Redhill Station when the log was moved from the dispatch queue to sub queue at 14.13” (on 28th March 2025). The medical cause of death was found to be 1a) Multiple Traumatic Injuries 9. CIRCUMSTANCES OF DEATH Shay Middleton-Pierce failed to attend school on the morning of 28th March 2025, and notified a friend via SnapChat that he had gone to London “because I wanted to die and I know too many spots in Redhill so I came here to make it more effort so I maybe give up”. Shay’s school informed Surrey Police that he was missing and of this information from the friend. Surrey Police were also made aware of Shay’s location, which his friend was able to see on SnapChat. Initially this was at London Bridge Station and British Transport Police (“BTP”) were updated and deployed officers to attend there as a Grade 1 incident. However, Shay then got on a train back to Redhill and Surrey Police updated BTP with this information. The BTP Communications Officer sent the log to the dispatch queue, with the intention that the Dispatcher would then action to police units. However, the Dispatcher moved the log from the dispatch queue to the sub queue, which meant no further action was taken at that time by BTP to establish whether officers could have been deployed to meet the train in time at Redhill Station and Surrey Police were not informed that BTP were not attending. Shay then met friends in Redhill during the course of the day. Shay was not classified as a missing person by Surrey Police until 22.54 on 28th March 2025. Surrey Police did not speak to Shay’s friends until around 22.13 that evening. The officers tasked with looking for Shay were diverted to another incident at 2.46am on 29th March 2025 due to competing demands on the service. No further action was taken to locate Shay until the incident leading to his death occurred on the morning of 29th March 2025, , sustaining multiple traumatic injuries which were not survivable. The Dispatcher at BTP was unable to explain why he had moved the log to the sub queue other than that this was a human error. 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 Dispatcher in the Control Room at British Transport Police was unable to explain why he had moved the log from the dispatch queue to the sub queue, other than due to human error. This meant that the log was not treated as a priority and there was a missed opportunity to consider deploying officers to attend Redhill Station to locate Shay, or to update Surrey Police that they would not be attending to see if they were able to deploy officers. The Court heard evidence from the communications officer who had moved the log to the dispatch queue and from the dispatch officer who had moved the log to the sub queue. The Team Manager and Service Delivery Manager for BTP’s Force Control Room also gave evidence regarding expectations for dispatchers to deploy a unit or add a significant update before removing the incident from the dispatch queue. These actions did not take place. Following conclusion of the inquest, the Court has heard and received further evidence from a Chief Inspector at BTP that, following an incident in March 2023, where issues were identified concerning lack of command and control where there was a threat to life identified, the Operations Manual was implemented in which it is documented that supervisory oversight is required for all immediate and priority grade calls, and the “CW log must be endorsed by a Force Incident Manager/Deputy Force Incident Manager/Team Manager to confirm their review and supervisory oversight”. Further the Court heard that this was subject to a recent review and updated and training was being undertaken to ensure all relevant staff were aware of this. None of the BTP witnesses gave evidence that there was an expectation that Shay’s log had to be endorsed in this way by a senior officer and this did not take place despite the learning from the March 2023 incident. The Court has received further evidence from BTP surrounding ongoing training and compliance monitoring in this regard, but given that this incident repeated concerns from the 2023 incident, it appears that further action is required to ensure that a priority log cannot be removed from the dispatch queue to the sub queue as a result of human error by a single dispatcher. The MATTERS OF CONCERN are as follows: A dispatcher at BTP can move the log from the dispatch queue to a sub queue in error and this has been documented to have occurred on at least two occasions where a person’s life was considered to be at risk. This effectively removes the log from the dispatcher’s attention for action. There are no computer checks to prevent this from happening and a system to prevent this with senior officers having oversight of such cases was not referred to in evidence by BTP staff. 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: 1. Shay Middleton-Pierce’s Parents 2. Surrey Police 3. Independent Office for Police Conduct 4. Carrington School 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.
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.
Not Protectively Marked 2 July 2026 Ms Anna Loxton HM Assistant Coroner for Surrey C/O Surrey Coroner’s Office Dear Ms Loxton Inquest into the Death of Shay Middleton-Pierce Regulation 28 Report to Prevent Future Deaths The following is provided in response to the Report to Prevent Future Deaths (the Report) arising from the Inquest into the Death of Shay Middleton-Pierce, as required under paragraph 7(2) of Schedule 5 of the Coroners and Justice Act 2009 and under regulation 29 of the Coroners (Investigations) Regulations 2013. British Transport Police (BTP) recognises HM Coroner’s concerns and is committed to ensuring that the circumstances identified are addressed robustly. We again extend our sincere condolences to the family of Shay Middleton-Pierce. Coroner’s Concern HM Coroner has identified a risk whereby a dispatcher in BTP’s Force Control Room (“FCR”) could move an incident log from the dispatch queue on the computer system to a sub-queue in error, removing it from active oversight from Team Managers and Force Incident Managers within the FCR. This means that actions on an urgent case were not progressed and contributed to a lack of communication with partner agencies. BTP acknowledges that, at the time of the incident, safeguards to prevent or detect such an error were insufficiently robust in practice. BTP confirms that the matters raised have been subject to detailed review. Measures have been implemented and are continuing to be embedded to significantly reduce the likelihood of recurrence to as low as reasonably practicable, via an integrated leadership, management oversight and training response complemented by exploring potential additional software system controls. Operational Roles and Accountability Force Incident Managers (FIMs), Deputy FIMs (DFIMs), and Team Managers (TMs) provide the supervisory structure within the FCR. Not Protectively Marked Not Protectively Marked They are responsible for: • Assessment and grading of incidents. • Command and control of operational activity. • Deployment of resources to critical incidents. • Continuous monitoring of incidents involving threat, harm, or vulnerability. In practical terms: • FIMs and DFIMs provide strategic and tactical command oversight of incident management, including review of immediate and priority incidents, decision- making, and escalation. • Team Managers provide direct supervision of around 8 dispatchers and call handlers, ensuring logs are progressed appropriately and that operational standards are met. The Operations Manual clearly requires that all priority and immediate incidents must be subject to active supervisory review and endorsement. Strengthened Supervisory Oversight and Controls Recognising that supervision by the FIM/DFIM and Team Managers is a critical safeguard, BTP has implemented a comprehensive set of procedural and supervisory controls: Embedding Mandatory Oversight • All Command and Control logs (CW logs) are to be actively reviewed and endorsed by a FIM, DFIM, or Team Manager before being progressed or deprioritised. Immediate and priority incidents are reviewed by FIMs/DFIMs; welfare-related scheduled incidents are reviewed by Team Managers. • • Team Managers and/or FIMs/DFIMs are to verify that appropriate deployment decisions and inter-agency communications have been completed before any log leaves active management. • This expectation has been reinforced through mandatory one-to-one training with all supervisory staff. Review of Team Manager Workloads • A structured review of Team Manager workloads is underway, aimed at removing non-operational tasks, to ensure focus on operational supervision. The review will conclude by July 2026. Increased Leadership Capacity • Revised rostering models are also being consulted to help safeguard consistent supervisory coverage during peak demand periods. Not Protectively Marked Not Protectively Marked Training and Capability Development Targeted Supervisory Training An intensive one-to-one training programme for all FIMs and DFIMs commenced in April 2026, providing a full 8-hour day of training for each FIM/DFIM every 10 weeks, including: • Command and control expectations. • Application of the Operations Manual. • Oversight responsibilities in threat-to-life incidents. • Decision-making and accountability. All supervisors will complete this programme by September 2026. Force Control Room Staff Training • Dispatchers and call handlers receive 7 weeks of initial raining on call handling and on radio talk-groups. Upon completion of this initial training, each Dispatcher / call handler is assigned a tutor who supports their ongoing development in live control room. Each call handler / dispatcher must satisfy a set of competency criteria in the live control room before they can be signed off as able to act independently as a call handler / dispatcher. • Our current programme of ongoing training for call handlers and dispatchers, providing a full 8-hour day of training for each FIM/DFIM every 10 weeks, is being delivered in partnership with BTP Learning & Development, with completion expected by Q3 2026. • FCR staff are now being provided with the same Railway Safety Awareness training as operational BTP Officers. Scenario-Based Learning BTP is introducing new immersive, scenario-based training using a simulated control room environment to: • Practice real-time incident management. • Reinforce THRIVE decision-making: o Threat: Is there an immediate danger or threat to life? o Harm: What is the potential level of harm or damage? o Risk: What is the likelihood of the threat or harm escalating? investigative opportunities, o Investigation: Are there opportunities, or evidence to be gathered? forensic o Vulnerability: Is the caller, victim, or person of interest particularly vulnerable? o Engagement: What is the most appropriate action, agency, or engagement required to resolve the incident safely? • Improve communication with partner agencies. Not Protectively Marked Not Protectively Marked This training will be delivered to all teams from November 2026. Improved Processes and Operational Guidance Operations Manual The existing Operations Manual has been implementation: reinforced with strengthened • Delivered through direct one-to-one engagement. • Supported by daily compliance monitoring. • Clearly defining supervisory roles and escalation requirements. Additional embedding has been completed for supervisory roles and will be completed for all staff by July 2026, with ongoing inclusion in new staff onboarding. FIM Guide • A new FIM Guide has been developed as a practical reference for supervisory staff, setting out consistent expectations for command and control. Monitoring, Audit and Performance Management THRIVE Compliance • Daily THRIVE compliance reviews are now undertaken by FCR management, and any deviations are addressed through formal performance management processes. Impact of Measures The combined effect of these measures ensures that: • A dispatcher acts in union with supervisory oversight. • Any movement of a log (e.g. into a sub-queue) is subject to active supervision and review by a Team Manager, and also by a FIM/DFIM in the case of Immediate and priority incidents. • FIMs/DFIMs or Team Managers are accountable for ensuring: o Deployment decisions are made. o Partner agencies are informed. o Threat-to-life risks are actively managed. In practical terms, were a similar situation to arise as that that arose in relation to Shay Middleton-Pierce: • The log would be reviewed and endorsed by a FIM/DFIM before any change in status. • Failure to deploy or communicate would be identified by the FIM/DFIM immediately. The FIM/DFIM would intervene to ensure appropriate action is taken. Not Protectively Marked Not Protectively Marked Technology Opportunities As part of an cohesive approach, BTP is exploring with the provider of its FCR Information Technology system whether a technological software safeguard or prompt could be developed to either reduce the potential for this user error, or to add an additional supervisory control on the computer system before a log is released from a sub-queue dispatch control group. This will be examined to accompany the controls of the current command and control system, balanced against the overall significant daily service demand and other operational requirements. Summary BTP fully acknowledge the seriousness of HM Coroner’s concerns. While software- based prevention is explored, BTP has implemented a comprehensive integrated framework of: • Strengthened supervision. • Enhanced training. • Clear operational guidance. • Continuous monitoring and accountability. These measures collectively ensure that the identified concern has been significantly reduced and is subject to ongoing review. There remains a legitimate operational need for logs to move between queues and control groups in certain cases; however, the strengthened supervisory framework maximises the opportunities to ensure that any errors are identified and corrected. We again extend our sincere condolences to the family of Shay Middleton-Pierce. Yours faithfully British Transport Police Not Protectively Marked
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