James Sheppard: Prevention of Future Deaths Report

Department of Health and Social Care
The Chief Executive Gloucestershire Health & Care NHS Foundation Trust (“The Trust”)

I am Roland Wooderson Area Coroner for the coroner area of Gloucestershire

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.

On 30 June 2023 I commenced an investigation into the death of James Oliver Sheppard born on 10 July 1980. The investigation concluded at the end of the inquest on 8 May 2025. The conclusion of the inquest was a narrative conclusion summarised as in box 4 below.

The deceased had a history of mental health difficulties. He was assessed by the local mental health team on 23 June 2023. The evidence was that had there then been a bed available in a local psychiatric hospital, the recommendation of the team would have been for detention under the provisions of the Mental Health Act 1983. Such a bed was not available and he continued to be treated as a voluntary patient in the community.

On 27 June 2023 a train was in collision with the deceased [REDACTED] in Gloucestershire.

The train driver said that the deceased had dived into the track immediately ahead of the train. He described the deceased’s actions as being deliberate and not accidental.

The evidence was clear that the deceased took his own life and intended to so do.

During the course of the inquest the evidence revealed matters 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. –

There appear to be insufficient beds available in psychiatric units to meet patient demand.

In my opinion action should be taken to prevent future deaths and I believe you AND/OR your organisation have the power to take such action.

You are under a duty to respond to this report within 56 days of the date of this report, namely by 26 June 2025 I, the coroner, may extend the period.
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 sent a copy of my report to the Chief Coroner and to the following Interested Persons namely the

Gloucestershire Health & Care NHS Foundation Trust and the family of Mr Sheppard

I am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.