Natalie Ainsworth: Prevention of future deaths report
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Date of report: 17/03/2026
Ref: 2026-0162
Deceased name: Natalie Ainsworth
Coroner name: Janine Richards
Coroner Area: County Durham and Darlington
Category: Suicide (from 2015)
This report is being sent to: Durham Police
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1 The Chief Constable of Durham Police | |
| 1 | CORONER I am Janine RICHARDS, Assistant Coroner for the coroner area of County Durham and Darlington |
| 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 14/02/2025 12:05an investigation was commenced into the death of Natalie Louise AINSWORTH 13/10/1995. The investigation concluded at the end of the inquest on 13/03/2026 00:00. The conclusion of the inquest was that Natalie Louise Ainsworth, aged 29 years, was found deceased on the 13th of February 2025 at 37 Tweed Terrace, Stanley, County Durham. [REDACTED] |
| 4 | CIRCUMSTANCES OF THE DEATH Natalie Louise Ainsworth, aged 29 years, was found deceased on the 13th of February 2025 at 37 Tweed Terrace, Stanley, County Durham. [REDACTED] |
| 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) Natalie was a vulnerable missing person considered to be at medium risk. A call was made to Police on the 13th February 2025 at 15:01 hours expressing concern for Natalie’s welfare and informing Police of a new address where she may be and informing Police that she had earlier threatened to take her own life. Although the control room recorded that information was passed on to the relevant officer, neither the Inspector who undertook an updated a risk assessment some two hours later, nor the Officer making enquiries, was aware that Natalie had threatened to take her own life. This important information was therefore not part of the risk assessment and not factored into subsequent Police actions, including in terms of whether to force entry to the property which was visited by the Police. Further the risk assessment carried out at 1704 hours was not a robust assessment of the risks which were known, or ought to have been known, by Police at that time. In particular the risk assessment fails to consider Natalie’s vulnerability as a person with a history of mental health issues, self harm and substance abuse, records incorrectly that there is no indication that the person is likely to take their own life, records incorrectly that the person has no mental health issues, and records incorrectly that the person has not been involved in a violent incident prior to them disappearing. An accurate and robust assessment of risk is essential to ensure that the nature and extent of any Police response is proportionate, and resources deployed appropriately, particularly when welfare/safety concerns are raised, as they were in Natalie’s case. |
| 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 May 12, 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] I have also sent it to Police and Crime Commissioner 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. 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. |
| 9 | 17/03/2026 Janine RICHARDS Assistant Coroner for County Durham and Darlington |