“(brief summary of matters of concern) The level of training and understanding of relevant…”
Dated 27 Jan 2026, from the coroner for Hampshire, Portsmouth and Southampton. 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 24 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 dated27 Jan 2026
- Deadline24 Mar 2026
- Published on judiciary.uk29 Jan 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Isle of Wight NHS Trust | Response publishedPublished on judiciary.uk in January 2026. |
The coroner’s concerns
(brief summary of matters of concern) The level of training and understanding of relevant call handling procedures and processes by those employed as call handlers in relation to incidents concerning hanging: 1 The procedures direct a Category 1 response (7 minutes) when the person has the means to suspend themselves and has stated that is there present intention. The call handler believes that a Category 1 response is, "When they are going to die now". Regulation 28 – After Inquest Document Template Updated 30/07/2021 2 The procedures direct that when the call handler does not have all relevant information they should telephone the person and ask questions in relation to the person's present situation. The call handler was on the Isle of Wight. THORNTON was in Southsea. The call handler did not call THORNTON as she felt she was too remote (geographically).
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, 2026-0040
- 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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