Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026/0281, written 28 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 | 28 May 2026 |
|---|---|
| Reference | 2026/0281 |
| Deceased | Alex Robinson |
| Coroner | John Ellery |
| Coroner area | Shropshire, Telford and Wrekin |
| Organisation named | Midlands Partnership University NHS Foundation Trust · The Shrewsbury and Telford Hospital NHS Trust |
| Source | judiciary.uk record |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
JOHN ELLERY H.M. SENIOR CORONER FOR SHROPSHIRE, TELFORD & WREKIN AREA H.M. Coroner’s Service Guildhall Frankwell Quay Shrewsbury Shropshire SY3 8HQ Coroner's Office: 01743 258540 Email: coroner@shropshire.gov.uk REPORT TO PREVENT FUTURE DEATH REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS Please do not include any living persons’ names in this document, in accordance with the Chief Coroner’s PFD Publication Policy (2026) CORONER 1 I am John Ellery, H.M. Senior Coroner, for the coroner area of Shropshire, Telford & Wrekin. 2 DATE OF REPORT 28 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. The Chief Executive of Shrewsbury & Telford Hospital NHS Trust (SaTH) You are under a duty to respond to this report within 56 days of the date of this report, namely by 23 July 2026. I, the coroner, may extend the period. 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 See paragraph 10 below 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 11 September 2025 I commenced an investigation into the death of Alex Alfred ROBINSON, aged 36 years [Your summary must include the following details] The medical cause of death was I (a) Suspension by Neck (b) (c) (d) II How, when and where On 10 September 2025 West Mercia Police were called to Church Lane, Little Wenlock, Telford following reports of an unresponsive male who had ligatured himself declared deceased at the scene. . Sadly, the male was Conclusion Suicide CIRCUMSTANCES OF THE DEATH 9 See paragraph 10 below 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: Alex Alfred Robinson was admitted to the Royal Shrewsbury Hospital (RSH) on the 8 September 2025 when he was seen in the same day emergency centre by the consultant on call. That consultant has made a statement and in paragraph 12 sets out his plan including “arrange review by mental health liaison team (MHLT). Following discussion, MHLT provided advice and a leaflet to be given to the patient as they are not available on site out of hours to review the patient physically”. In a later statement (in paragraph 3) the consultant further states “I was not present at that moment when the resident doctor discussed with MHLT service, but she informed me that MHLT informed her they will not be available to see Mr Robinson at that time”. 2 Subsequent inquiry with MHLT stated clearly that Midlands Partnership Foundation Trust (MPFT) Mental Health Liaison Team at RSH is a 24/7 service, they had the usual night cover of cover of two staff on the 8/9 September 2025 and that no formal referral was ever received. This conflicting information represents a lost opportunity for Alex to have received appropriate care from MPFT which may have prevented Alex from killing himself on the 10 September 2025, but this cannot be known. 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] 1. Partner of Alex 2. The Chief Executive, Midlands Partnership NHS Foundation Trust (MPFT) 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 9 3
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.
JOHN ELLERY H.M. SENIOR CORONER FOR SHROPSHIRE, TELFORD & WREKIN AREA H.M. Coroner’s Service Guildhall Frankwell Quay Shrewsbury Shropshire SY3 8HQ 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: The H.M. Senior Coroner John Ellery for the Coroner Area Shropshire, Telford & Wrekin in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following an inquest into the death of Alex Alfred ROBINSON that concluded on 20 May 2026. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, NAME: , Group Chief Medical Officer provides this response within 56 days (plus any extension granted) of the date of the Report to Prevent Future Deaths. DATE OF RESPONSE: 21 July 2026 1 2 3 CONFIRMATION OF CORONER’S MATTERS OF CONCERN the MATTERS OF CONCERN were identified in the report are as follows: Alex Alfred Robinson was admitted to the Royal Shrewsbury Hospital (RSH) on the 8 September 2025 when he was seen in the same day emergency centre by the consultant on call. That consultant has made a statement and in paragraph 12 sets out his plan including “arrange review by mental health liaison team (MHLT). Following discussion, MHLT provided advice and a leaflet to be given to the patient as they are not available on site out of hours to review the patient physically”. In a later statement (in paragraph 3) the consultant further states “I was not present at that moment when the resident doctor discussed with MHLT service, but she informed me that MHLT informed her they will not be available to see Mr Robinson at that time”. 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. Thank you for your report sent to the Chief Executive of Shrewsbury and Telford NHS Trust on 28th May 2026, relating to preventing future deaths. This followed the tragic death of Alex Robinson, and I would like to express how sorry I am about the terrible impact that this had on Alex’s family and friends. We have reviewed the care provided by SaTH on the 8th September 2025. To add to the information provided to the inquest, I have sought clarity on the sequence of events leading up to the advice received from mental health professionals on that day. The resident doctor who saw Mr Robinson estimates that she would have spoken to the Mental Health Liaison Team (MHLT) health care professionals between 9.30 pm and midnight on the 8th September. She advised she called from the doctor’s office from one of the doctor’s phones in what used to be the old Acute Medical Assessment Area. The resident doctor advised she called the number that is listed on the MHLT page on the intranet. . Our resident doctor explained that the healthcare professional who answered the call advised Mr Robinson’s presentation would not be within their remit as it was an ‘normal and expected reaction’ for someone going through a significant life event such as breaking up with a long-term partner as Mr Robinson was. The resident doctor remained concerned and therefore asked if she could visit the MHLT office (by bereavement office at SaTH) to discuss. The resident doctor went to their offices but unfortunately cannot recall any of their names. She relayed the information once again to the MHLT who again reiterated it was not unusual due to the life event and offered some leaflets which she took which are the ones presented in the notes. The resident doctor remained concerned as Mr Robinson was not eating or drinking but relied upon the advice given by MHLT. As MHLT advised it was not within their remit, the resident doctor did not feel the need to make a formal referral. The resident doctor was not aware of the formal online form at the time however did not question any further following the advice she was given by MHLT. We have confirmed that photocopies of the leaflet that our resident doctor indicated had been given to her by MHLT are in Mr Robinson’s notes and the original leaflets were provided to Mr Robinson. We have checked our switchboard records, and these confirm that a call was made from extension which is located in the doctor’s office and made to the MHLT, extension at 23:19pm on 8th September 2025. Representatives from MPFT have confirmed that they have no record of the above and confirmed that they have not had a formal referral. We have identified that a formal referral involves completing of the online form. Our conclusion and learning from this is that all contact with MPFT needs to be documented on the online referral form and a copy kept in the notes. We believe this should resolve any ambiguity about advice received and therefore potentially reduce the risk that level of concern for a patient’s mental health has not been fully understood. We will also reiterate to staff the importance of recording the name of any healthcare professional who has given advice in the medical notes. We will provide Trust-wide communications to highlight the need to use the online referral form. 5 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
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