CORONER I am Jeremy Chipperfield, Senior Coroner, for the coroner area of County Durham and Darlington.
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DATE OF REPORT 1st September 2026
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CORONER’S 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.
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THIS REPORT IS BEING SENT TO 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.
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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.
SUMMARY OF CORONER’S CONCERN Absence of a reliable safeguard for identification and communication of safety- critical information in SystmOne.
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ACTION SHOULD BE TAKEN 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.
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INVESTIGATION AND INQUEST 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
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CIRCUMSTANCES OF DEATH 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 56th 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.
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CORONER’S CONCERNS 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 ofsafety- 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.
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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 2. [REDACTED] Family solicitor 3. [REDACTED] Spectrum Solicitor 4. [REDACTED] TEWV Solicitor 5. [REDACTED]Government Legal Department 6. [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.
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