Jake Girton: Prevention of future deaths report
Date of report: 29/09/2025
Ref: 2025-0488
Deceased name: Jake Girton
Coroner name: Graeme Irvine
Coroner Area: East London
Category: Alcohol, drug and medication related deaths
This report is being sent to: [REDACTED], The Commissioner of Police of the Metropolis |
[REDACTED]
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: [REDACTED], The Commissioner of Police of the Metropolis [REDACTED] | |
| 1 | CORONER I am Graeme Irvine, senior coroner, for the coroner area of East London |
| 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made |
| 3 | INVESTIGATION and INQUEST On 26th January 2024, this court commenced an investigation into the death of Jake Hickey Girton aged 41 years. The investigation concluded at the end of the inquest on 25th September 2025. The court returned a narrative conclusion. “Jake Hickey Girton was found deceased at home on 26th January 2024, his death was caused by alcohol and dihydrocodeine toxicity on a background of cardiorespiratory illness. It has not been possible to credibly explore Jake’s intent at the time of his death, he was intoxicated by alcohol.” Mr Hickey Girton’s medical cause of death was determined as; 1a Acute Respiratory Failure 1b Combined Drug And Alcohol Use II Ischaemic Heart Disease, Fatty Liver Disease, Chronic Obstructive Pulmonary Disease |
| 4 | CIRCUMSTANCES OF THE DEATH Steven Hart was remanded to HMP Bedford on 30 November 2022. He had a documented history of mental health issues, including anxiety, depression, paranoia, self-harm, and suicidal ideation. During his time in custody, he experienced several episodes of self-harm and was intermittently supported through the ACCT (Assessment, Care in Custody and Teamwork) process. In March 2023, following a prison lockdown and a period without access to his usual coping mechanisms and medication, Mr Hart’s mental health deteriorated further. On 25 March 2023, after an earlier incident where he was found with a [REDACTED] around his neck, he was not referred for further risk assessment as required by protocol. Later that evening, he was found unresponsive in his cell, having used a ligature attached to a faulty observation panel. He was taken to hospital but died on 29 March 2023 from asphyxiation due to hanging. |
| 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. Evidence heard from a Metropolitan Police Inspector at inquest indicated that the police officer who was investigating the offence for which Jake was arrested was under an obligation to inform that complainant (the hospital) of Jake’s release from custody. There is no evidence to suggest this was done. Evidence from the Psychiatric trust at inquest indicates that on the 17th January 2024, there were under the impression that Jake would remain in police custody, and had they known he was released, greater efforts may have occurred to support Jake in the community. 2. Despite a Directorate of Professional Standards review, there is no evidence that the MPS identified any shortcoming in their performance in dealing with Jake, consequently no evidence exists of any reflection or remediation of this failing. |
| 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 22nd November 2025 . 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 Mr Girton. I have also sent it to the local Director of Public Health 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 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 | [DATE] 29 September 2025 [SIGNED BY CORONER] |