Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0264, written 20 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 | 20 May 2026 |
|---|---|
| Reference | 2026-0264 |
| Deceased | PM |
| Coroner | Ian Potter |
| Coroner area | Kent & Medway |
| Source | judiciary.uk record |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
OFFICIAL
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 Mr. Ian Potter, Area Coroner for Kent and Medway.
2. DATE OF REPORT
20 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.
3. THIS REPORT IS BEING SENT TO
1. Chief Constable of Kent Police
You are under a duty to respond to this report within 56 days of the date of this report, namely
by 15 July 2026. I, the coroner, may extend the period if an appropriate application is made.
OFFICIAL
OFFICIAL
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
The concerns relate to:
(cid:127) Lack of policy / procedure for minimising suicide risk and safety-netting those released
from police custody following an arrest for offences known to have significantly
increased risks.
(cid:127) No requirement for officers to receive ongoing I updated training regarding the
conducting of welfare checks for those thought to be at risk of self-harm / suicide.
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 you have the power to take such action.
OFFICIAL
OFFICIAL
7. INVESTIGATION and INQUEST
On 23 June 2025 an investigation was commenced into the death of [PM], aged 44 Years.
The investigation concluded at the end of the inquest on 13 May 2026. The conclusion of the
inquest was 'Suicide'.
The deceased was last seen alive at his home address by a friend and a police officer at 21:36
on 18 June 2025, following concerns for his welfare. At about 19:20 on 19 June 2025, the
deceased was found partially suspended
the fact of death shortly thereafter. The deceased died as a result of the ligature around his
neck, which was applied after he had taken a
actions with the intention of ending his life.
overdose. He took those
. An ambulance was called but sadly a paramedic verified
I a Ligature Around The Neck
1b
1c
1d
II
Overdose
8. CIRCUMSTANCES OF THE DEATH
On the 18th June 2025 , Kent Police officers arrested the deceased on suspicion of an offence
contrary to section 160 of the Criminal Justice Act 1988. A search of his home address was
conducted under section 18(1) PACE and a number of electrical devices were seized. It was
acknowledged that those arrested for this type of offence are at a significantly heightened risk
of self-harm / suicide, particularly within the first 48 hours following release from police
custody.
Police officers undertook a number of risk-assessments on him during his time in police
custody and there was also an assessment by the Liaison and Diversion Service. No specific
risks were noted.
Once released on bail (late afternoon / early evening of 18 June 2025), police officers
understood the situation to be that he had no mobile devices and no home telephone, and he
would therefore be unable to contact family members or support services, if he wished. He
was advised that he was permitted to purchase another mobile telephone and that his service
provider would be able to transfer his current number to a new phone. As it happens, but
entirely unknown to police officers at the time, his work mobile telephone and laptop had not
been seized. As such, he would have had the means to make contact with others had he
wished to do so.
Family become concerned for his welfare on the evening of 18 June 2025. A friend attended
his home address but initially got no response and therefore requested police to conduct a
welfare check. This was undertaken and the police officer was satisfied that there was no
immediate risk and that he had made plans for the following day.
In the early evening of 19 June 2025, he was found deceased inside his home address.
OFFICIAL
OFFICIAL
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:
1. Part of the evidence in this inquest was that Kent Police does not have its own policy or
standard operating procedure regarding the risk assessing and safety-netting of those arrested
for this type of offence. I was directed to Operational Advice from the College of Policing (June
2019) entitled “Managing the risk of suicide for persons under investigation for online child
sexual abuse and exploitation” ('the Advice’). It was confirmed that the Advice is available to
officers on the Kent Police intranet. However, the nature of the Advice is such that some of it's
content is not suitable for individual officers to make case-by-case assessments and decisions
without there being an organisational level policy or procedure in place. While it is accepted, in
the particular circumstances of this case, that parts of the Advice (e.g. paragraph 3.9) would
not have altered the outcome, the concern remains regarding future risks to others.
2. 1 heard evidence that, following initial basic training, officers at Kent Police are not required
to undertake any face-to-face update or refresher training regarding welfare checks that they
undertake regularly in the community. For the avoidance of doubt, I found that relevant officer
undertaking the welfare check on the evening of 18 June 2025 was 'kind and compassionate'
and did 'her best to conduct the welfare check'; however, it is not difficult to see that a lack of
ongoing training raises risk in the future.
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. Family of the deceased
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
OFFICIAL
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.
OFFICIAL Chief Coroner RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 When a coroner sends a prevention of future deaths (PFD) report to a person or organisation, they must respond within 56 days. Recipients of a PFD report can apply to the coroner for an extension. A response to a PFD report must detail the action taken or to be taken, whether in response to the report or otherwise, or it must explain why no action is proposed. The purpose of the response template below is to promote clarity, ensure that responses address the coroner’s concerns directly and transparently, and support consistency and good practice across organisations and sectors. It does not restrict how a person or organisation formulates their response; recipients remain responsible for determining what action is appropriate and for ensuring that their response accurately reflects the steps taken or planned. In accordance with the Chief Coroner’s PFD Publication Policy (2026), any representations regarding publication of a response should be sent to the coroner. These representations should be made at the same time as the response is provided. The coroner will pass any representations received to the Chief Coroner for a decision. 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: Mr. Ian Potter, Area Coroner for Kent and Medway in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following an inquest into the death of [PM], that concluded on 13 May 2026. 1. RESPONDENT OFFICIAL OFFICIAL In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, The Chief Constable of Kent Police provides this response within 56 days (plus any extension granted) of the date of the Report to Prevent Future Deaths. 2. DATE OF RESPONSE 02 July 2026 3. CONFIRMATION OF CORONER’S MATTERS OF CONCERN Part of the evidence in this inquest was that Kent Police does not have its own policy or standard operating procedure regarding the risk assessing and safety-netting of those arrested for this type of offence. I was directed to Operational Advice from the College of Policing (June 2019) entitled “Managing the risk of suicide for persons under investigation for online child sexual abuse and exploitation" (‘the Advice’). It was confirmed that the Advice is available to officers on the Kent Police intranet. However, the nature of the Advice is such that some of it's content is not suitable for individual officers to make case-by-case assessments and decisions without there being an organisational level policy or procedure in place. While it is accepted, in the particular circumstances of this case, that parts of the Advice (e.g. paragraph 3.9) would not have altered the outcome, the concern remains regarding future risks to others. I heard evidence that, following initial basic training, officers at Kent Police are not required to undertake any face-to-face update or refresher training regarding welfare checks that they undertake regularly in the community. For the avoidance of doubt, I found that relevant officer undertaking the welfare check on the evening of 18 June 2025 was 'kind and compassionate' and did 'her best to conduct the welfare check'; however, it is not difficult to see that a lack of ongoing training raises risk in the future. 3. DETAILS OF ACTION TAKEN, how has the concern been addressed. [If no action is proposed please explain why here]. 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. Kent Police does have a Suspect Welfare and Suicide Strategy standard operating procedure (SOP N11e) in place. However, we have identified that staff awareness and familiarity with the guidance is not as strong as it should be. In response, we have reviewed and updated the policy to make it more comprehensive and to incorporate relevant elements of the Authorised Professional Practice (APP) that were not previously included. As part of the initial intelligence work a suicide risk assessment is completed prior to allocation to the Officer in the case (OIC) and immediately when a suspect is identified. This is included on the Intel package and is passed to the OIC - Before the suspect is aware of the investigation. Whilst this is standard practice, this is not explicitly covered in our policy N11e - the policy will be updated accordingly to ensure a more cohesive bond to APP exists in the new wording. Research has been undertaken with other police forces to understand their approaches to providing mobile phones to POLIT (police on line investigation Team) suspects where a need has been identified. Having considered the various practices and the current financial pressures facing the force, Kent Police will not be adopting this approach. OFFICIAL OFFICIAL Instead, the policy will be amended to require QIC’s to consider providing suspects with key contact numbers to support their welfare and enable them to maintain contact with their support network. This information can be incorporated into the notes section of the Suspect Information Pack. In addition, officers should consider offering suspects the opportunity to use a telephone at the police station prior to departure to contact family members, friends, or other appropriate support services where necessary. This approach seeks to balance welfare considerations with the efficient use of force resources, while ensuring that suspects are provided with reasonable opportunities to access support following their release from police custody. To improve awareness, the revised policy will be circulated to staff and promoted through a Spotlight communication. In addition, it will be incorporated into continuing professional for development (CPD) activity, September/October, which will be open to the wider force. The policy will also be specifically covered within CPD for POLIT officers. These actions will be completed within the next fortnight. including a Public Protection CPD event scheduled We also utilise a comprehensive Suspect Information Pack, which is currently being refreshed. In support of the above measures, the Detective Chief Inspector in (POLIT) has met with the Chief Inspector, who leads the Medway district where [PM] died. The Chief Inspector will oversee the delivery of refresher training on welfare checks, aligned with the force-wide Right Care, Right Person (RCRP) refresher programme. This training will highlight the increased risk of suicide among suspects under investigation for child sexual abuse offences and reinforce the importance of considering support from mental health services and other relevant agencies where there are concerns regarding an individual's welfare. Due to the scale of delivery and the number of officers requiring refresher training, implementation will take longer than the other actions outlined above. The anticipated timeframe for completion is approximately six months. 4. 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. SIGNATURE SIGNATUR1 OFFICIAL
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