Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0292, written 10 Jun 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Jun 2026 |
|---|---|
| Reference | 2026-0292 |
| Deceased | Lesley Higginson |
| Coroner | Jacqueline Devonish |
| Coroner area | Cheshire |
| 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. 2. 3. CORONER I am Jacqueline DEVONISH, Senior Coroner, for the coroner area of Cheshire. DATE OF REPORT 10 June 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 North West Ambulance Service (NWAS) You are under a duty to respond to this report within 56 days of the date of this report, namely by July 31, 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 The ambulance service declined to attend a ‘welfare call’ to the home of an elderly resident which had been raised by an organisation commissioned specifically to confirm daily contact with the resident. The reason provided for declining to accept the call was that it was not known whether the resident was inside the address. 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 27 January 2026 I commenced an investigation into the death of Lesley Katherine HIGGINSON aged 72. The inquest concluded on 4th June 2026. 9. CIRCUMSTANCES OF DEATH Ms Higginson, a medically vulnerable adult, was found deceased at her home address on 18 January 2026 following a concern for welfare raised by neighbours. Due to a desire to remain in her own home and not be attended by carers several times a day, Adult Social care arranged a package of care through SOS Homecare including medication management (epilepsy and other medication) and remote welfare checks. Alertacall, was commissioned to ensure remote contact with her on a daily basis through a call button service known as the Okay Each Day Service. Alertacall had been unable to speak to her over the weekend she died. Mrs Higginson also benefitted from a remote medication delivery service, The Medication Support Company. A new medication safe and computer screen had been installed in her home on 13 January 2026 which was operated remotely at fixed times of the day. She had not answered the calls on Friday 16 January resulting in a team member visit to her home. She was present. On Saturday 17 January there was no contact with her by the medication team, and in accordance with the medication support policy an escalation visit would be due after 24 hours of no contact. A plan was made to visit to check on her welfare on Sunday 18 January but she had died prior to this visit being conducted. In accordance with Alertacall policies and prior agreement with Mrs Higginson, a neighbour was contacted on Saturday 17 January and asked to conduct a welfare check. The neighbour, reported back that contact had not been established. Alertacall then escalated to the emergency services. The police declined attendance for a welfare call. The ambulance service accepted the welfare call initially but later called back rejecting the request to attend stating it was not their policy to accept welfare checks if there is no confirmation someone is in the property. Alertacall recontacted the neighbour who then reported having seen Mrs Higginson out riding her scooter with the dog that day. The escalation was closed having established contact with a neighbour. On Sunday 18 January, there was no answer from Mrs Higginson to Alertacall and the neighbour raised concerns confirming that emergency services had been contacted. The ambulance service arrived at 12:34, and entry was forced by the Cheshire Fire and Rescue Service, finding Mrs Higginson deceased on her bed, and confirmed her death at 13:03. 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: Mrs Higginson benefitted from a care package designed for her independence and welfare, engaging a remote means of making daily contact with her in the least intrusive manner. Failed contact was followed up by a call to the ambulance service which indicated that they would not attend. It is important to know whether there is an established policy for declining welfare calls, and if so, when it was introduced. It leaves patients in a difficult position when aligned with the constabulary Right Care Right Person (RCRP) policy which was published nationally on 23 June 2023 and implemented in the Cheshire region in January 2024. The RCRP policy states that the police in Cheshire (and in other areas nationally) will not respond to welfare check calls when healthcare are best placed to support those who may be in crisis. It is unclear from the ambulance service response whether a request for a welfare check, in the circumstances of this death, is to be deemed to be healthcare related and whether the ambulance service properly rejected the request, on the grounds stated. 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: Next of kin Director of Alertacall The Medication Support Company Cheshire East Adult Safeguarding Cheshire Constabulary 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 Jacqueline DEVONISH Senior Coroner for Cheshire
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.
Ms Jacqueline Devonish His Majesty’s Senior Coroner Cheshire Coroners Court By Email Only 21 July 2026 Dear Ms Devonish LADYBRIDGE HALL 399 Chorley New Road Bolton BL1 5DD nwas.nhs.uk Regulation 28 Report – Inquest Touching the Death of Lesley Katherine Higginson I write further to your Prevention of Future Deaths Report dated 10th June 2026, which was issued to North West Ambulance Service (“NWAS”) following the conclusion of the inquest touching the death of Lesley Katherine Higginson. I am aware that you will share my response with Lesley’s family, and I firstly wish to express my sincere condolences to them. NWAS’ core purpose is to save lives, prevent harm and provide services which optimise the likelihood of positive patient outcomes. Through the Regulation 28 report, you have requested that NWAS considers your matters of concern. By this letter I will address those concerns as far as I am able. I note that the inquest took place on 4th June 2026 and that NWAS did not have Interested Person (IP) status. NWAS provided witness evidence from Connor Hayes, Paramedic, on 5th February 2026 though he was not called to give evidence. Therefore, no NWAS witnesses or representatives were in attendance at the hearing. Through the Regulation 28 report, you have requested that NWAS considers your matters of concern and have suggested that action is taken to prevent future deaths occurring in the future. Within this letter, I will address those concerns raised as far as I am able. Mrs Higginson benefitted from a care package designed for her independence and welfare, engaging a remote means of making daily contact with her in the least intrusive manner. Failed contact was followed up by a call to the ambulance service which indicated that they would not attend. It is important to know whether there is an established policy for declining welfare calls and when it was introduced. It leaves patients in a difficult position when aligned with the constabulary Right Care Right Person (RCRP) policy which was published nationally on 23 June 2023 and implemented in the Cheshire region in January 2024. The RCRP policy states that the police in Cheshire (and in other areas nationally) will not respond to welfare check calls when healthcare are best placed to support those who may be in crisis. It is unclear from the ambulance service response whether a request for a welfare check, in the circumstances of this death, is to be deemed to be healthcare related and whether the ambulance service properly rejected the request, on the grounds stated. Headquarters: Ladybridge Hall, 399 Chorley New Road, Bolton BL1 5DD Delivering the right care, at the right time, in the right place; every time. On 17th of January 2026 at 15:16 hrs a call was received from Okay Each Day, a wellbeing check service, in which the caller advised that they had attempted to contact Ms Higginson on their daily call but had not received a response. During this call, they advised that a neighbour of Ms Higginson’s had advised that they had cameras for each other, and she had seen no movement of Ms Higginson on the cameras. This call elicited an ambulance response, and the caller was advised that there was a 1 hour 20 minute to 1 hour 50 minute response time but they may receive a call back from a Health Care Professional within that timeframe. This was accepted by the caller. An Advanced Paramedic called Okay Each Day back at 15:35hrs and advised that due to the location of Ms Higginson being unknown and a medical need for an ambulance also being unknown, an ambulance would not be deployed. This advice was in accordance with the NWAS Concern for Welfare policy, which covers the receipt, recording, escalation and NWAS responses in relation to concern for welfare of a patient. Where such calls are received, the guidelines provide that the patient’s location needs to be known and there needs to be a confirmed medical need. NWAS need a verified location and assurance that a patient is indeed present at the specified location where an ambulance resource is being dispatched to. Additionally, NWAS rely on accurate contact information, ensuring that any provided contact number will connect us directly with the patient. NWAS does not have the legal powers, nor the equipment, to force entry to properties. As an ambulance service, our primary function is to prioritise and respond to the medical needs of our patients whether this is face-to-face or via other methods. A confirmed physical or mental health complaint means that the caller has evidence or good reason to believe that the patient or service user is currently suffering from a physical or mental health issue that requires either a face-to-face assessment or telephone response. It cannot be assumed that an individual being uncontactable, means that they require medical assistance. Nor do NWAS have the capacity to conduct thorough enquiries, on behalf of other services, to determine whether an individual is experiencing physical or mental health concerns. It is incumbent upon these services to arrange for and execute such inquiries autonomously. The NWAS Mental Health and Suicide Prevention Lead has listened to the 999 calls made in respect of Ms Higginson and has confirmed that the 999 call from Okay Each Day at 15:16 hrs was handled appropriately and in line with the Concern for Welfare policy. It could not be determined that Ms Higginson was at the specified location nor could it be determined that she had a confirmed physical or mental health complaint. It was therefore correct that NWAS did not deploy an ambulance to Ms Higginson based on the information provided at the time of the call. A subsequent call was received at 11:49 hrs on 18th January 2026. The caller was a neighbour of Ms Higginson who stated that a foot could be seen on the floor. NWAS then deployed an ambulance which arrived within 54 minutes, at 12:43 hrs. Ms Higginson was sadly declared deceased on scene at 13:03 hrs. The Concern for Welfare Response Criteria Guidelines Policy was introduced in May 2024, in response to the Right Care, Right Person (RCRP) National Partnership Agreement. NWAS have been clear and transparent with local system partners, including the Police, Acute Trusts, Mental Health Organisations and Councils regarding the deployment of ambulances when concern for welfare calls are made to the service and the circumstances in which an ambulance will and will not be deployed. NWAS and other system partners have previously noted that there is a gap in services for members of the public who may need concern for welfare call outs and this has been discussed in both strategic and tactical RCRP meetings, but not something that NWAS are able to fulfil unilaterally. NWAS have also met with the Okay Each Day service who have been advised as to the circumstances in which an ambulance will and will not be deployed when concern for welfare calls are received. It was recommended by NWAS that Okay Each Day explore whether they could set up a pathway with other agencies to make initial contact with a patient where their exact location cannot be determined or for them to consider their own response team to conduct these enquiries I am grateful to you for bringing this matter to my attention and I am sorry that you felt it necessary to issue a Prevention of Future Deaths Report to NWAS. If you require any further clarification or information, please do not hesitate to contact me or the Trust’s Deputy Director of Corporate Affairs, Emma Shiner. Yours sincerely Chief Executive
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