Jack Brown: Prevention of future deaths report
Hospital Death (Clinical Procedures and medical management) related deaths
Date of report: 18/11/2025
Ref: 2025-0593
Deceased name: Jack Brown
Coroner name: Sophie Lomas
Coroner Area: Northamptonshire
Category: Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: Secretary of State for Health and Social Care
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: Secretary of State for Health and Social Care | |
| 1 | CORONER I am Sophie LOMAS, Assistant Coroner for the coroner area of Northamptonshire |
| 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 On 10 February 2023 I commenced an investigation into the death of Jack Richard BROWN aged 86. The investigation concluded at the end of the inquest on 24 October 2025. The conclusion of the inquest was that Mr Brown died due to natural causes. |
| 4 | CIRCUMSTANCES OF THE DEATH Mr Brown was an 86 year old gentleman who had been admitted to a care home following a hospital stay for heart failure and hyponatraemia. He was suffering from delirium and required constant 1:1 observations, along with help with all activities of daily living. Against that background, on the evening of 25th January 2023 Jack was assisted to the toilet by the night carer. He was sleepy and indicated that he wanted to stay on the toilet. He remained on the toilet asleep between approximately 9.30pm and 7.30am. Attempts were made during that time to rouse him but he remained asleep. At 8am on 26th January 2023 a handover of care staff took place and the day carer raised a concern that Mr Brown was unresponsive. Further staff checked Mr Brown and recognised that he had sadly died. His death was confirmed by paramedics who attended the scene. A post-mortem examination concluded that Mr Brown had died due to ischemic heart disease. |
| 5 | CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) At the inquest the court heard evidence that care agencies who provide agency care staff to care / nursing homes do not need to register with the CQC and are not regulated by any other body. The activites of such agencies are therefore not inspected or checked to ensure that they have rigerous recruitment processes and there is no one to report matters to when a concern is identified. This gives rise to a concern as care homes may rely on agencies to vet agency carers and have minimal input into suitability and training for the role. This creates a risk that agency care staff, who may be wholly unsuitable for the role, are providing care to vulnerable people without basic checks as to experience and suitability. This places service users at risk of harm and gives rise to a risk that future deaths could occur. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 January 13, 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 The family of Jack Brown [REDACTED] [REDACTED] [REDACTED] I have also sent it to Care Quality Commission (CQC) who may find it useful or of interest. 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 person who I believe may find it useful or of interest. |
| 9 | Dated: 18/11/2025 [REDACTED] Sophie LOMAS Assistant Coroner for Northamptonshire |