PM
Response Status
Report Content
Coroner
I am Mr. Ian Potter, Area Coroner for Kent and Medway
Legal Powers
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DATE OF REPORT 20 May 2026
Legal Powers
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
Your Response
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary
Action Required
SUMMARY OF CORONER’S CONCERN The concerns relate to: • Lack of policy / procedure for minimising suicide risk and safety-netting those released from police custody following an arrest for offences known to have significantly increased risks. • No requirement for officers to receive ongoing I updated training regarding the conducting of welfare checks for those thought to be at risk of self-harm / suicide
Action Required
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In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe you have the power to take such action.
Investigation and Inquest
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On 23 June 2025 an investigation was commenced into the death of [PM], aged 44 Years. The investigation concluded at the end of the inquest on 13 May 2026. The conclusion of the inquest was ‘Suicide’. The deceased was last seen alive at his home address by a friend and a police officer at 21:36 on 18 June 2025, following concerns for his welfare. At about 19:20 on 19 June 2025, the deceased was found partially suspended. An ambulance was called but sadly a paramedic verified the fact of death shortly thereafter. The deceased died as a result of the ligature around his neck, which was applied after he had taken a [REDACTED] overdose. He took those actions with the intention of ending his life.
Details
- Report Date
- 20 May 2026
- Coroner
- Ian Potter
- Coroner Area
- Kent & Medway
- Reference
- 2026-0264
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If you need support right now:
Samaritans — 116 123, free, 24 hours
SOBS (Survivors of Bereavement by Suicide) — 0300 111 5065, 9am–9pm
Cruse Bereavement — 0808 808 1677, weekdays 9am–5pm