Joanna Hillard: Prevention of future deaths report
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Date of report: 05/03/2026
Ref: 2026-0128
Deceased name: Joanna Hillard
Coroner name: Samantha Marsh
Coroner Area: Somerset
Category: Suicide (from 2015)
This report is being sent to: Department of Health and Social Care
 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
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| THIS REPORT IS BEING SENT TO: 1. Secretary of State for Health and Social Care, [REDACTED] | |
| 1 | CORONER I am Samantha Marsh senior coroner, for the coroner area of Somerset. |
| 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 the 26th February 2021, my predecessor, Mr Tony Williams, commenced an investigation into the death of Joanna Hillard. The investigation concluded at the end of the inquest, heard by me, on the 26th February 2026. The conclusion of the inquest was Box 3: Joanna HILLARD, aged 64, was discovered [REDACTED] at her home address at around 09:18hrs on the Twenty-Fifth of February 2021. She was last seen alive at 22:30hrs the evening before and so it is not known exactly when she [REDACTED] Despite CPR she could not be revived and was pronounced deceased by the attending paramedic. Joanna’s specific motivation to act as she did is not fully clear on the evidence available, but on the balance of probabilities derived from her low mood due to a coercive and controlling domestic relationship and her social and living circumstances, and this has more than minimally contributed to her death. Box 4: Suicide contributed to by coercive and controlling behaviour |
| 4 | CIRCUMSTANCES OF THE DEATH [REDACTED] [REDACTED] The inquest explored whether [REDACTED] behaviour was caused by either his Parkinsons or the Pramipexole medication he was prescribed. His Parkinsons Nurse, after liaising with his Consultant, told friends and professionals that this was unlikely because [REDACTED] was on such a low dose and such behavioural changes are more commonly seen with much higher doses than [REDACTED] was on. One of the findings at the Inquest was that [REDACTED] condition and/or properly prescribed medication did not cause his behaviour but on the balance of probabilities it exacerbated underlying personality traits. From September of 2019 [REDACTED] embarked on a relentless campaign to embarrass, belittle intimidate and control Jo, and isolate her from her friend and family. The inquest heard examples of this: (i) Her finances were controlled ([REDACTED] forced her to relinquish her carers allowance by frightening her into thinking she was committing fraud. This meant that she had no access to independent financial means). (ii) He made her recount in mortifying detail [REDACTED], friends, family and neighbours her [his perception of her] sexual inadequacies [REDACTED] Witnesses explained that Jo was a private and dignified person and she would have found this experience utterly humiliating and mortifying. (iii) [REDACTED] had found a Filippo bride online. He [REDACTED] but insisted that they remain living together in the home so that Jo could continue to care for him once his Filipino bride and her relative had obtained a visa; with the four of them living in the house together. (iv) He tried to bully Jo into signing her [REDACTED] home over to him, which would have left her homeless and with nothing. (v) Jo engaged a solicitor to help her [REDACTED] property matters and once [REDACTED] found out about this, he made her end the retainer, meaning that she had no independent and factually correct advice about her position and her rights; it was only what [REDACTED]was telling her. (vi) She had to contact her children, friends and family in secret as her conversations were monitored, or [REDACTED] could be heard in the background telling Jo what she was to say. The coercion and control continued even when they were not physically together. In February 2020 Jo was taken by family to Scotland. Whilst there Phillip phoned her relentlessly for hours throughout the day and night until she went home. In March 2020 [REDACTED] went to the Philippines to meet his internet-bride and during his absence still controlled Jo’s movements, what she did and who she spoke to etc. [REDACTED] remained living together. Whilst administrative processes were in place for his internet-bride to be granted a visa, there were no firm plans or date when she was expected to be in the country and/or living with them. Evidence from family was that the situation had settled a bit by November 2020. On the 25th February 2021, Jo was discovered [REDACTED] in the workshop/garage attached to the[REDACTED] home. [REDACTED] left the UK after Jo’s death to live in the Philippines, where it is understood he still resides, and so there has been no investigation, prosecution or conviction under Section 76 of the Serious Crime Act 2015. During her lifetime Jo did not/would not support a prosecution. I was satisfied that Jo was not happy in her living situation but did not feel able to leave because (i) she had been brainwashed (to quote the family’s phrase) by [REDACTED] into believing all of this was her fault and so she felt guilty and that she ‘owed him’ and it was therefore her duty to say and (ii) she wanted to protect [REDACTED] from his behaviour which he also exhibited towards them when he was unable to control Jo to the extent and degree that he wanted. He would use his Parkinsons Disease as a weapon and would continually play the consummate victim (even though he was anything but). [REDACTED] The Court heard from a variety of professionals who were either directly involved with Jo, or involved ‘behind the scenes’ trying to protect and safeguard her. The IDVA (Independent Domestic Violence Advocate) told the Court that this was the worst example of coercion and control that she had seen in her 16 years of experience. Multiple professionals from domestic abuse and safeguarding units/organisations and departments were involved with Jo. All agreed that whenever she spoke it was a regurgitation of [REDACTED] narrative; what he wanted, what he needed, how he viewed things; she had lost the ability to identify and say “I” want/need/think/feel. She was stuck in a relentless cycle of self-blame; enforced on her by [REDACTED] . Her family described her as being “brainwashed”. [REDACTED] controlled her thoughts and decision making process even when he wasn’t in the room with her (and professionals, quite appropriately, insisted on seeing Jo on her own. They also had to see her on her own due to covid and the requirement for social distances). The physical separation did not make a difference; the mental and emotional control was still there. All professionals trying to support Jo agreed that what they wanted for her, and what she needed to be able to recover, was to leave [REDACTED] , but she would not do this due to the coercion and control. All professionals were equally ‘professionally frustrated’ by their lack of power to take decisions in her best interests to keep her safe. Jo was assessed, under current legislation (the Mental Capacity Act 2005) as having capacity to make decisions to remain living with [REDACTED], even if those decisions were regarded by others as unwise. |
| 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. The provisions of the Mental Capacity Act 2005 (which Jo was assessed under) , pre- date the Serious Crime Act 2015, particular Section 76 which relates to the offence of controlling and coercive behaviour. The Mental Capacity Act 2005 aims to ensure that people with social care needs who have an impairment of their brain or mind are supported to make their own decisions, wherever possible, on a background of least-restrictive options to curtail someone’s liberty and freedom of action. People should be assumed to have mental capacity unless it can be demonstrated otherwise. The Mental Capacity Act only applies if at the material time he/she is unable to make a decision for himself/herself in relation to the matter because of an impairment of, or disturbance in the functioning of, the mind or brain” (Section 2(1)) MCA 2005). I am concerned that there is a lack of understanding of the effects of controlling and coercive behaviour on a person’s ability to make a decision in their best interests. I am concerned that people who live in a level of fear (resultant from coercive and controlling behaviour) may have their decision-making abilities negatively affected and the law surrounding capacity, as currently drafted, does not recognise this. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. |
| 7 | YOUR RESPONSEYou are under a duty to respond to this report within 56 days of the date of this report, namely by 30th 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: (i) Joanna’s family (ii) Somerset Foundation Trust (iii) Avon & Somerset Constabulary (iv) Somerset Council Adult Social Care (v) Langport Surgery I have also sent it to the following who may find it useful or of interest. Refuge of [REDACTED] Women’s Aid of [REDACTED] Safe Lives of [REDACTED] AAFDA of [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 | 5th March 2026 |