Matthew Brierley: Prevention of Future Deaths Report

Police related deathsSuicide (from 2015)

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Date of report: 08/01/2025 

Ref: 2025-0008 

Deceased name: Matthew Brierley 

Coroners name: Nicholas Shaw 

Coroners Area: Cumbria 

Category: Suicide (from 2015) | Police related deaths 

This report is being sent to: Ministry of Justice | National Police Chiefs’ Council | College of Policing

THIS REPORT IS BEING SENT TO:   

1) [REDACTED], Secretary of State for Justice
2) [REDACTED], Staff Officer to National Police Chiefs’ Council
3) [REDACTED], CEO College of Policing
1CORONER

I am Dr Nicholas Shaw, HM Assistant Coroner for Cumbria
2CORONER’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
3INVESTIGATION and INQUEST

On 1st May 2024 I commenced an investigation into the death of Matthew BRIERLEY, aged 39. The investigation concluded at the end of the inquest on 16th December 2024 . The short form conclusion of the inquest was one of Suicide 
Medical cause of death was 1a Asphyxia
4CIRCUMSTANCES OF THE DEATH

The record of inquest was as follows: “Matthew Brierley died in the carpark of Buttermere  Court Hotel, Buttermere, Cumbria on 24th April 2024. He was under great personal stress due to a police investigation and bail conditions imposed. It is most likely that this stress caused him to take his own life by [REDACTED] asphyxiation”.                                                                   
 
Matthew had been arrested at his home in Fareham on 16th March, Hampshire police having received information that he was linked to a Paypal account used to purchase indecent  images of children in 2023. Matthew denied the allegation in a “no comment” interview and was bailed pending enquiries and examination of his computer and mobile devices. Bail  conditions precluded him from living or sleeping at home or having any unsupervised contact  with his biological children or stepdaughter. His employers the Border Force were also  informed and Matthew was suspended from work. On 23rd April Matthew left Hampshire  driving north to Buttermere, a place that had special meaning for him. The following morning  he was found deceased in his car [REDACTED]. He left several final messages in his car. 
5CORONER’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 will 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]

(1) It is recognized that men in Matthew’s circumstances are at a markedly elevated risk of  suicide. Several papers refer to this – I found Kothari et al (Journal of Forensic and Legal  Medicine, July 2021) particularly informative. They quote 3.2% of those arrested in operation Notarise committing suicide and explore reasons why this group is particularly vulnerable.   

(2) I was told that when released on bail Matthew was informed that examination of devices  and a decision in his case might take up to 18 months. Being suspended from work and  unable to live at home removed normality and stability from Matthew and likely impaired his  ability to cope with his situation. The length of time taken to reach a decision seems  excessive, prolonging the time Matthew would be at risk. I was told devices can be “triaged” within a matter of days or more quickly, surely cases such as this should be dealt with more  expeditiously? It seems that “standard” bail conditions are applied but I am not aware of any suggestion of a specific risk to Matthew’s stepdaughter, might a more detailed individual  assessment of risk be helpful? I should record that Matthew’s phone was examined after his death and that images found were not of a grade that would have led to a prosecution. 

(3) Police acknowledged the increased risk and completed a standard assessment form  when Matthew was released – he denied any risk and also declined referral to Liaison and  Diversion service. A Family Contact Officer was also appointed but the onus remained on  Matthew to seek help and there was no proactive contact which might have been helpful as men in Matthew’s situation are less likely to seek help due to feelings of shame and  embarrassment.
6ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe you and our organizations have the power to take such action. 
7YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by 5th March 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. 
8COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
Matthew’s widow and father. I have also sent it to DI [REDACTED] of Hampshire Constabulary who may find it useful or of interest. 

I am also under a duty to send the Chief Coroner a copy of your response.
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 by the Chief Coroner. 
98th January 2025
Signature
Dr Nicholas Shaw, HM Assistant Coroner for Cumbria