“(brief summary of matters of concern) The evidence at the inquest revealed that the…”
Dated 17 Feb 2026, from the coroner for Bedfordshire and Luton. 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
Deadline passedReplies were due by 14 Apr 2026. A reply may have been sent and not yet published.
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.
- Report dated17 Feb 2026
- Deadline14 Apr 2026
- Published on judiciary.uk23 Feb 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Ministry of Justice | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| HMP Bedford | Response publishedPublished on judiciary.uk in February 2026. |
| Northamptonshire Healthcare NHS Foundation TrustNamed in the report as “Northamptonshire Healthcare Foundation Trust” | Response publishedPublished on judiciary.uk in February 2026. |
The coroner’s concerns
(brief summary of matters of concern) The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence. In this instance this confusion resulted in Eddie not being observed; had these checks and monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not recognised and escalated. It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols. Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford Prison. Regulation 28 – After Inquest Document Template Updated 30/07/2021
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, 2026-0097
- 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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