Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0324, written 15 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 | 15 Jun 2026 |
|---|---|
| Reference | 2026-0324 |
| Deceased | Aaron Hamer |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester North |
| Source | judiciary.uk record |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Minister of State for Prisons, Probation and Reducing Reoffending Ministry of Justice 102 Petty France London SW1H 9AJ 1 | CORONER | am Joanne Kearsley, Senior Coroner for the coroner area of Greater Manchester North. 2 | CORONER’S LEGAL POWERS | 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 | INVESTIGATION and INQUEST On 34 July 2025 | commenced an investigation into the death of Mr Arron Hamer. The investigation concluded at the end of the inquest on 11" June 2026. The conclusion of the inquest was that Mr Hamer died as a result of Suicide whilst he was in custody at HMP Buckley Hall. His medical cause of death was 1a) Global Hypoxic Ischaemic Brain Injury as a result of hanging. 4 | CIRCUMSTANCES OF THE DEATH The brief circumstances are that Mr Hamer was sentenced in 2009, at the age of 17 and received a 2 % year tariff on an Indeterminate Public Protection sentence. He had a background of significant childhood trauma having witnessed an attempt murder at the age of 7. His family had had to be relocated as a result. He suffered significant bullying at his new school and between the ages of 7-10 he self-harmed. He was taken into care at the age of 11 and began using drugs. His offending was linked to his drug use. Following his sentence in 2009 he remained in custody until 2022. He was then released on licence but recalled in 2023 following a positive drugs test. He had moved to HMP Buckley Hall on the 30" April 2025. He had positively engaged with a number of professionals including probation, drug and alcohol team, his keyworker and had started trauma therapy. On the 18" June 2026 he was found hanging his in cell. Upon finding Mr Hamer the Prison Officers did not cut the ligature for nearly three minutes or commence CPR. It was heard that they panicked and were visibly distressed on finding Mr Hamer. They had undertaken their basic life support training years ago on their initial prison officer training. 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters 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) The Court heard there is no mandatory refresher training on basic life support for prison officers after they have conducted their initial prison officer training. If they do the first aid at work course this has to be refreshed every three years but only certain officers do this. For the majority they do not have refresher training. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10th August 2026. I, the coroner, may extend the period. 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons Mr and MSI Family) and HMP Buckley Hall Prison. lam also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 15th June 2026 HM Senior Coroner Joanne Kearsley A2
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.
Joanne Kearsley Senior Coroner Greater Manchester HM Coroner’s Court Floors 2 and 3 Newgate House Newgate Rochdale OL16 1AT Director General of Operations HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ 10 August 2026 Dear Ms Kearsley, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR AARON HAMER Thank you for your Regulation 28 report dated 6 March 2026, addressed to following the inquest into the death of Aaron Hamer at HMP Buckley Hall on 21 June 2025. I am responding on behalf of the Minister for Prisons and Probation and the Ministry of Justice. I understand that you will share this response with Mr Hamer’s family. I would like to begin by expressing my sincere condolences for their loss. Every death in custody is a tragedy, and ensuring the safety of those in our care remains our highest priority. Your report raises a concern that there is no mandatory First Aid refresher in basic life support for prison staff. All new prison officers receive Emergency First Aid training as part of their initial foundation programme, which includes instruction in cardiopulmonary resuscitation (CPR). This training is mandatory, remains valid for three years, and is subject to local requalification to ensure staff maintain the necessary level of competence. The HMPPS First Aid Policy Framework, reissued nationally in August 2023, sets out requirements for both Emergency First Aid at Work (EFAW) and First Aid at Work (FAW). It places responsibility on Governors to ensure that sufficient first aid provision is always available within the establishment. This is achieved through a comprehensive local First Aid Needs Assessment, conducted in line with the First Aid at Work Regulations, which determines A3 the number of trained staff required to provide an effective emergency response within each establishment. To support ongoing staff capability, HMPPS provides a range of refresher materials and learning resources designed to maintain and enhance first aid knowledge and skills. This includes bespoke “first-on-scene” video content developed in partnership with St John Ambulance, which offers practical guidance for prison officers and frontline staff responding to emergencies prior to the arrival of healthcare professionals. There is also a CPR learning bulletin that provides guidance for staff on action to take when someone is found unresponsive, not breathing and/or has no pulse in accordance with guidance from Resuscitation Council UK. Thank you again for bringing these important matters to my attention. I hope this response provides assurance that appropriate action is being taken to address the issue raised. Yours sincerely, Interim Director General of Operations A4
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