“Mr Hand made a 999 to EMAS at 04:36 hours”
Dated 14 Aug 2026, from the coroner for Northamptonshire. 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
Report put online after its 56 daysOrganisations 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.
judiciary.uk put this report online on 19 Oct 2026, after the 56 days for replies had ended (9 Oct 2026). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated14 Aug 2026
- Deadline9 Oct 2026
- Published on judiciary.uk19 Oct 2026
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in October 2026. |
| NHS England | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 19 Oct 2026, after the 56 days for replies had ended (9 Oct 2026). These dates can’t tell us whether a reply was due before it went online. |
| East Midlands Ambulance Service NHS TrustNamed in the report as “East Midlands Ambulance Service” | Response publishedPublished on judiciary.uk in October 2026. |
The coroner’s concerns
Mr Hand made a 999 to EMAS at 04:36 hours. During this call he clearly stated he had taken a significant overdosemg tablets of and an unknown quantity of mg of He clearly expressed suicidal ideation. Evidence was given at the inquest that the reason for the category 3 disposition was that the “conversation did not disclose any of the high risk drugs that enable a higher disposition. Under the NHS Pathways this is a category 3.” It is clear that no consideration was given to the number of tablets taken when deciding the relevant category for disposition. Concentration appears to be entirely on the type of drugs used. 11. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: Mother of Samuel Hand Father of Samuel Hand I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. 12. SIGNATURE Anne PEMBER Senior Coroner for Northamptonshire
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, 2026-0418
- Added to Minute Book
- 20 Oct 2026
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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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