Source · Prevention of Future Deaths

Natalie Ainsworth

Ref: 2026-0162 Date: 17 Mar 2026 Coroner: Janine Richards Area: County Durham and Darlington 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryImportant information about a threat to take her own life was not passed to officers, leading to an insufficiently robust risk assessment that did not consider Natalie's vulnerability or accurately record her history.

Date 17 Mar 2026
56-day deadline 12 May 2026 est. estimated from the report date
Responses identified 1 of 1
Suicide (from 2015)

Coroner's concerns

AI summary
Important information about a threat to take her own life was not passed to officers, leading to an insufficiently robust risk assessment that did not consider Natalie's vulnerability or accurately record her history.
View full coroner's concerns
Natalie was a vulnerable missing person considered to be at medium risk. A call was made to Police on the 13th February 2025 at 15:01 hours expressing concern for Natalie's welfare and informing Police of a new address where she may be and informing Police that she had earlier threatened to take her own life. Although the control room recorded that information was passed on to the relevant officer, neither the Inspector who undertook an updated a risk assessment some two hours later, nor the Officer making enquiries, was aware that Natalie had threatened to take her own life. This important information was therefore not part of the risk assessment and not factored into subsequent Police actions, including in terms of whether to force entry to the property which was visited by the Police. Further the risk assessment carried out at 1704 hours was not a robust assessment of the risks which were known, or ought to have been known, by Police at that time. In particular the risk assessment fails to consider Natalie's vulnerability as a person with a history of mental health issues, self harm and substance abuse, records incorrectly that there is no indication that the person is likely to take their own life, records incorrectly that the person has no mental health issues, and records incorrectly that the person has not been involved in a violent incident prior to them disappearing. An accurate and robust assessment of risk is essential to ensure that the nature and extent of any Police response is proportionate, and resources deployed appropriately, particularly when welfare/safety concerns are raised, as they were in Natalie's case.

Responses

1 respondent

Durham Constabulary

Police / Law Enforcement
Letter dated 12 May 2026 PDF
AI-classified response stance Action Taken
AI-generated response summary

• The Force reviewed processes for recording additional information received into the Force Control Room during missing person investigations. • Changes were made to how information is recorded and shared, including a new process for Control Room staff to directly input updates into the missing person enquiry log and contact the Investigating Officer. • The Constabulary had reviewed its Missing From Home Policy and Guidance and provided updated training on vulnerability and risk factors.

View full response
Dear Ms Richards Durham Constabulary Response to the Regulation 28; Report To Prevent Future Deaths relating to the case of Natalie Louise AINSWORTH DOB 13/10/1995 issued at conclusion of the inquest on 13/03/2026 Since the issuing of the notice the Force have reviewed processes around the recording of additional information received into the Force Control Room as part of a missing person investigation. As a result, changes have been made to how that information is recorded and shared with those engaged in enguiries to locate the missing person and to ensure that all information is readily available to those conducting reviews of risk assessments. The new process is that the member of Control Room staff will now directly input the new or updated information into the missing person enquiry log whilst also making direct contact with the Investigating Officer to ensure that they are aware of the update’s presence in that log. The Control Room Incident (Storm) log will also reflect that this entry has been made, recording the detail of the message passed to the Investigating Officer alongside the time of the update. (For example Officer A was contacted by radio at 1300 hours and informed of the newly identified address, 123 High Street.) This will ensure that a clear record of the update is available to the Investigator and subsequent reviewing Supervisor. In the period between the death of Natalie AINSWORTH and the inquest conclusion the Constabulary had already reviewed it’s Missing From Home Policy and Guidance and provided updated training to those conducting risk assessments. This focused around the recognition vulnerability and other risk factors and determining the appropriate response as a result. DU CO RHAM NSTABULARY INAN h O h EMERGENCY ,U ' ALWAYS ■ ■ CALL 999

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I trust that I have provided enough information to deal with your report but should you require any additional information please do not hesitate to contact me.

Report sections

Investigation and inquest
On 14/02/2025 12:05an investigation was commenced into the death of Natalie Louise AINSWORTH 13/10/1995. The investigation concluded at the end of the inquest on 13/03/2026 00:00. The conclusion of the inquest was that Natalie Louise Ainsworth, aged 29 years, was found deceased on the 13th of February 2025 at 37 Tweed Terrace, Stanley, County Durham.
Circumstances of the death
Natalie Louise Ainsworth, aged 29 years, was found deceased on the 13th of February 2025 at 37 Tweed Terrace, Stanley, County Durham.

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Report details

Reference
2026-0162
Date of report
17 March 2026
Coroner
Janine Richards
Coroner area
County Durham and Darlington

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 12 May 2026 (estimated from the report date).

Sent to

Durham Police

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