“(brief summary of matters of concern) Regulation 28 – After Inquest Document Template…”
Dated 29 Dec 2025, from the coroner for Cambridgeshire and Peterborough. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 23 Feb 2026.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated29 Dec 2025
- Deadline23 Feb 2026
- Published on judiciary.uk5 Jan 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Northamptonshire Healthcare NHS Foundation TrustNamed in the report as “Northamptonshire Healthcare Foundation Trust” | Response publishedPublished on judiciary.uk in January 2026. |
The coroner’s concerns
(brief summary of matters of concern) Regulation 28 – After Inquest Document Template Updated 30/07/2021 6 Whilst an inmate at HMP Peterborough Fallon ADAMS was prescribed methadone (for opiate withdrawal) and chlordiazepoxide (for alcohol withdrawal). She also took non-prescribed apparently obtained from an illicit source within the prison. All of these medications have a sedative effect which in combination have the potential to cause over sedation and death. The evidence seemed to show that at no stage was Ms ADAMS given a specific warning or advice stating that taking additional non-prescribed medication/ could result in over sedation and death. I also heard evidence in relation to Regulation 28 issues. Whilst it is clear that a number of relevant changes were being made it was not clear that a specific warning in relation to the risks of over sedation was being implemented.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0647
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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