David Thompson: Prevention of future deaths report
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Date of report: 10/02/2026
Ref: 2026-0080
Deceased name: David Thompson
Coroner name: Alison Longhorn
Coroner Area: Devon, Plymouth & Torbay
Category: Suicide (from 2015)
This report is being sent to: Devon & Cornwall Police
 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
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| THIS REPORT IS BEING SENT TO: 1. [REDACTED], Chief Constable, Devon & Cornwall Police. | |
| 1 | CORONER I am Alison Longhorn, Area Coroner for the coroner area of the County of Devon, Plymouth & Torbay. |
| 2 | 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 | INVESTIGATION and INQUEST A coronial investigation was commenced on 9th March 2023 into the death of David John Thompson, aged 46. The investigation concluded at the end of the inquest on 3rd February 2026. The conclusion of the inquest was suicide, and the medical cause of death was recorded as 1a) hanging. |
| 4 | CIRCUMSTANCES OF THE DEATH On 6th March 2023, David Thompson went missing from his home address. He had a history of low mood, had expressed thoughts of suicide previously, and had been experiencing a number of challenging life events in the weeks before. His partner reported him missing to the police and he was graded as a ‘medium risk’ missing person. He was located the following morning, [REDACTED]. |
| 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 inquest heard that when Mr. Thompson’s partner reported him missing to the police, she was repeatedly asked (by both the 999 call handler and the attending police officers) whether he had demonstrated any ‘suicidal ideation’. It was clear that she did not fully understand what that meant, and as a result information which would have been relevant to the consideration of the level of risk presented by Mr. Thompson going missing was not recorded by the police. (2) Furthermore, I heard evidence that the term ‘suicidal ideation’ was still being widely used by the constabulary when asking questions of members of the public who were reporting missing persons, and I am concerned that a member of the public may not understand what is being asked of them and may not therefore respond appropriately. (3) During the course of the inquest I heard evidence from 5 police officers and 2 members of police staff. When asked what their understanding of the term ‘suicidal ideation’ was, their answers were vague and inconsistent. There therefore appears to be a lack of understanding by those employed by the police as to what the term means, creating a danger that the risk posed by a missing person is not fully appreciated by staff responding to a missing person report. |
| 6 | ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths, and I believe you and your organisation have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 8th April 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. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED] [REDACTED] [REDACTED] [REDACTED] I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. |
| 9 | 10.02.26 Alison Longhorn |