- Patient repeatedly accessed and used an item provided by staff that could be adapted for self-harm, resulting in fatal self-ligation.
- Complete absence of any system to control vulnerable patients' access to materials easily adapted for self-harm, creating ongoing significant risk.
- Nottinghamshire Healthcare Trust and NHS England must respond within 56 days with actions or reasons for no action; responses will be published.
Date of report: 02/07/2026
Ref: 2026-0357
Deceased name: Rianna Poiana-Lazarec
Coroner name: Simon Burge
Coroner Area: Nottingham City & Nottinghamshire
This report is being sent to: Nottinghamshire Healthcare Trust | NHS England
| REGULATION 28: REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| 1 | CORONER I am Simon BURGE, Assistant Coroner, for the coroner area of Nottingham City and Nottinghamshire. |
| 2 | DATE OF REPORT 02 July 2026 |
| 3 | 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. |
| 4 | THIS REPORT IS BEING SENT TO 1. Nottinghamshire Healthcare Trust – NHCT 2. NHS England You are under a duty to respond to this report within 56 days of the date of this report, namely by September 3, 2026. I, the coroner, may extend the period if an appropriate application is made. |
| 5 | 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. I will pass any representations received to the Chief Coroner for a decision. 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. |
| 6 | SUMMARY OF CORONER’S CONCERN |
| 7 | 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. |
| 8 | CIRCUMSTANCES OF DEATH See attached |
| 9 | 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: However, whilst unobserved in her room, [REDACTED]. She had this on several previous occasions in the preceding eight weeks but had always been interrupted. The ease with which a) [REDACTED] and b) the complete absence of any system for controlling a vulnerable patient’s access to material which can easily be adapted for self-harming purposes, is a real concern. The staff gave evidence to the effect that they had no other [REDACTED] available to give patients. |
| 10 | 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: 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. |
| 11 | Simon BURGE Assistant Coroner for Nottingham City and Nottinghamshire |
The post Rianna Poiana-Lazarec: Prevention of future deaths report appeared first on Courts and Tribunals Judiciary.
Share Evidence Blueprint
Save to Google Notes
Search Google Scholar
Save as PDF
⭐ My Revision List
