State Custody related deaths
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October 3, 2025
Steven Hart: Prevention of future deaths report
Date of report: 24/09/2025 Ref: 2025-0487 Deceased name: Steven Hart Coroner name: Sean Cummings Coroner Area: Bedfordshire and Luton Category: State Custody related deaths | Suicide (from 2015) This report is being sent to: Governor [REDACTED], HM Chief Inspector of Prisons [REDACTED], CEO of HMPPS [REDACTED] REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT […]
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September 1, 2025
Masood Hamid: Prevention of futrue deaths report
Date of report: 20/08/2025 Ref: 2025-0434 Deceased name: Masood Hamid Coroner name: Joanne Kearsley Coroner Area: Manchester North Category: Hospital Death (Clinical Procedures and medical management) related deaths |State Custody related deaths This report is being sent to: Chief Executive Pennine Care NHS Foundation Trust | Chief Constable Greater Manchester Police | Chief Executive Oldham […]
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July 31, 2025
Lewis Petryszyn: Prevention of Future Deaths Report
Date of report: 31/07/2025 Ref: 2025-0394 Deceased name: Lewis Petryszyn Coroners name: Patricia Morgan Coroners Area: South Wales Central Category: State Custody related deaths | Wales prevention of future deaths reports (2019 onwards) This report is being sent to: Cwn Taf Morgannwg University Health Board | G4S Care & Justice Services UK Ltd REGULATION 28 REPORT […]
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July 30, 2025
Azroy Dawes-Clarke (3): Prevention of Future Deaths Report
Date of report: 29/07/2025 Ref: 2025-0391 Deceased name: Azroy Dawes-Clarke Coroners name: Ian Brownhill Coroners Area: Kent and Medway Category: State Custody related deaths This report is being sent to: His Majesty’s Prison and Probation Service REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Director General Chief Executive of His […]
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July 30, 2025
Azroy Dawes-Clarke (2): Prevention of Future Deaths Report
Date of report: 29/07/2025 Ref: 2025-0389 Deceased name: Azroy Dawes-Clarke Coroners name: Ian Brownhill Coroners Area: Kent and Medway Category: State Custody related deaths This report is being sent to: HMP Elmley | South East Coast Ambulance Service | Oxleas NHS Foundation Trust REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT […]
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July 30, 2025
Azroy Dawes-Clarke (1): Prevention of Future Deaths Report
Date of report: 29/07/2025 Ref: 2025-0388 Deceased name: Azroy Dawes-Clarke Coroners name: Ian Brownhill Coroners Area: Kent and Medway Category: State Custody related deaths This report is being sent to: Ministry of Justice | Department of Health and Social Care REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Secretary […]
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July 28, 2025
Michael Pugh: Prevention of Future Deaths Report
Date of report: 25/07/2025 Ref: 2025-0378 Deceased name: Michael Pugh Coroners name: Patricia Harding Coroners Area: Kent and Medway Category: State Custody related deaths | Suicide (from 2015) This report is being sent to: His Majesty’s Prison and Probation Service REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. [REDACTED], His […]
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July 28, 2025
Sheldon Jeans: Prevention of Future Deaths Report
Date of report: 25/07/2025 Ref: 2025-0376 Deceased name: Sheldon Jeans Coroners name: Rachael Griffin Coroners Area: Dorset Category: Alcohol, drug and medication related deaths | State Custody related deaths This report is being sent to: Department of Health and Social Care | HMPPS | HMP Guys Marsh | Oxleas NHS Foundation Trust REGULATION 28 REPORT […]
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July 23, 2025
Patryk Gladysz: Prevention of Future Deaths Report
Date of report: 18/07/2025 Ref: 2025-0364 Deceased name: Patryk Gladysz Coroners name: Priya Malhotra Coroners Area: Inner West London Category: State Custody related deaths | Mental Health related deaths This report is being sent to: HMPPS | Minister of State for Prisons | Ministry of Justice/HMP Wandsworth | Secretary of State for Health and Social […]
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July 16, 2025
Gavin Wheale: Prevention of Future Deaths Report
Date of report: 10/07/2025 Ref: 2025-0350 Deceased name: Gavin Wheale Coroners name: Ian Dreelan Coroners Area: Birmingham and Solihull Category: Alcohol, drug and medication related deaths | State Custody related deaths This report is being sent to: HM Prison & Probation Service REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: HM […]