“| heard evidence at inquest from ae ...: also had sight of a statement fron WE of…”

The coroner’s concerns

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— | heard evidence at inquest from ae ...: also had sight of a statement fron WE of Hampshire police that he attended RHCH at 05:55 after hospital staff contacted police to report the sudden death of Mr Berry. The officer queried with the sister in charge BEE why there had been such a delay (over 4 hours since death) in notifying police about the death. The officer was told that there had been some confusion about the correct procedure to contact police. It was known that Mr Berry was ' a heroin user and it had been suspected that he had consumed heroin prior to his death. It was noted that there were two small puncture wounds on Mr Berry's right forearm only one of which was caused by ambulance staff during treatment. GEE confirmed that hospital staff did not have the details of the address where Mr Berry was found so this necessitated IEEE in having to make further enquiries to try and locate the ambulance staff. IEEEEBmanaged to locate an ambulance technician EE, who was part of the second ambulance crew to arrive at i ee but the first attender EM had by then gone off duty. | was also told that when SCAS control room was contacted for the exact details, police were told that a private ambulance attended. PC Headen attended S| at 06:45 but it again took some time to discover the exact address as the building is multi-occupancy. It was therefore some 6 hours+ after death was confirmed that the officers were able to locate and speak to the occupants of the flat who found Mr Berry. On the evidence | heard, it seemed clear that the occupants were themselves under the influence of drugs. My concerns are: 1. Hospital staff did not contact police in what appeared to be a suspicious and unnatural death for several hours. Further, | was told there appeared to be confusion about the correct procedure with regards to notifying police. This suggests a possible need to revisit who, when and how hospital staff contact the police both before and after death in appropriate cases. 2. Although | was not shown the handover paperwork from the ambulance technicians to hospital staff, the lack of basic detail such as the address where Mr Berry was found may mean that handover procedures should be revisited especially if there is a private ambulance service involved. 3. Finally, the lack of an address may require further consideration of how basic but potentially important data is conveyed to SCAS control room from a private ambulance service especially before staff go off duty and thereby avoiding delay.

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, 2017-0232

Added to Minute Book

8 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