“(brief summary of matters of concern) 1”
Dated 6 Jan 2026, from the coroner for Greater Lincolnshire. Sent to 3 organisations or people.
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 3 Mar 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 dated6 Jan 2026
- Deadline3 Mar 2026
- Published on judiciary.uk8 Jan 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| East Midlands Ambulance Service NHS Trust | Response publishedPublished on judiciary.uk in January 2026. |
| Lincolnshire Police | Response publishedPublished on judiciary.uk in January 2026. |
| NHS England | Response publishedPublished on judiciary.uk in January 2026. |
The coroner’s concerns
(brief summary of matters of concern) 1. Despite a very clear recommendation made in a letter dated 24 July 2019 by DAC Twist on behalf of the NPCC that "police forces have established ABD protocols with their local ambulance service so that suspected ABD incidents are treated as medical emergencies (i.e. Cat 1, with a response time of 8 minutes)", there is still no such Regulation 28 – After Inquest Document Template Updated 30/07/2021 protocol in Lincolnshire. 2. Under the current NHS Pathways system, ABD does not have its own allocation pathway. 3. Under the current NHS Pathways system a referral for ABD will only be allocated a category 2 response in the absence of police restraint.
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, 2026-0004
- Added to Minute Book
- 8 Oct 2026
- Reuse
- 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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