Angela Montegomery

Date of report: 01/09/2026 Ref: 2026-0432 Deceased name: Angela Montegomery Coroner name: Jeremy Chipperfield Coroner Area: Durham and Darlington This report is being sent to: NHS England REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

I am Jeremy Chipperfield, Senior Coroner, for the coroner area of County Durham and Darlington.

1 st September 2026

1. [REDACTED], Chief Executive Officer, NHS England

You are under a duty to respond to this report within 56 days of the date of this report, namely by 28 October 2026. I, the coroner, may extend the period if an  appropriate application is made.

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.

Absence of a reliable safeguard for identification and communication of safety- critical information in SystmOne.

In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power  to take such action.

On 26 February 2024, I commenced an investigation into the death of Angela Mary Montegomery, aged 51. The medical cause of death: 1a) Drowning 1b) High levels of Venlafaxine How, when and where: Drowned [REDACTED] on 25 February 2024 on A Wing, Ground Floor, HMP Low Newton Conclusion: Suicide

Angela declared to the nurses conducting her secondary health screening interview that she intended to drown herself [REDACTED]. This fact was recorded  in SystmOne but not in a Note of Concern (ACCT commencement document) or any other prison records and it was not effectively communicated to any of  those in her subsequent ACCT procedure. None of the healthcare staff who viewed the record in the 55 days between  Angela’s screening and death communicated the fact of Angela’s statement of intent to prison staff. On the 56 th day after screening, Angela drowned [REDACTED]. The jury found that the failure to communicate Angela’s comment to prison staff and the failure to transfer it to the custodial record contributed to her  death.

During the course of the inquest I heard evidence giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In  the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: Absence of a reliable safeguard for identification and communication of safety- critical information in SystmOne. SystmOne (“S1”) is the patient-record system used in English prisons. Healthcare staff can access S1, but custodial staff cannot. Safety-critical  information cannot therefore affect custodial risk management unless  healthcare staff identify and communicate it. Information may be missed because it is buried within a lengthy record, is not  appropriately coded or highlighted, or is not captured by a particular search.  Although S1 has search functions, there is no automated or other system-level safeguard to identify safety-critical information and prompt its communication  to custodial staff when the necessary human action fails. I am concerned that custodial decisions may therefore be made or omitted due to lack of information likely materially to affect the management of a prisoner’s  risk. Similar concerns about the visibility, identification and communication of  safety-critical information within custodial record systems have been raised in a number of published Reports to Prevent Future Deaths, including the 9  reports hyperlinked in the annex hereto. 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:

1. [REDACTED], Brother and NOK of Angela Mary

Montgomery

1. [REDACTED] Family solicitor
2. [REDACTED] Spectrum Solicitor
3. [REDACTED] TEWV Solicitor
4. [REDACTED]Government Legal Department
5. [REDACTED] counsel for Government Legal Department

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 [REDACTED]