Source · Prevention of Future Deaths

Roger Ginger

Ref: 2026-0218 Date: 16 Apr 2026 Coroner: Ronald Wooderson Area: Gloucestershire Responses identified: 1 / 1

A recommendation from the Professional Standards Department, made in a report dated 9 July 2025, may not have been actioned.

Date 16 Apr 2026
56-day deadline 11 Jun 2026
Responses identified 1 of 1

Coroner's concerns

AI summary
A recommendation from the Professional Standards Department, made in a report dated 9 July 2025, may not have been actioned.
View full coroner's concerns
The recommendation of the Professional Standards Department may not have been actioned despite the recommendation being made in a report dated 9  July 2025

Responses

1 respondent
Gloucestershire Constabulary Police / Law Enforcement
25 Jun 2026 PDF
Action Taken

Gloucestershire Constabulary explains that the VIST form has been replaced by the Public Protection Notice (PPN), which is too complex for receptionists to complete. Instead, they have invested in and mandated additional vulnerability and 'Thrive+' principles training for all public-facing staff since October 2023 to ensure risk identification and appropriate PPN referrals are made by suitable officers. (AI summary)

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Dear Mr Wooderson, Death of Roger John Ginger
- Response to Report to Prevent Future Deaths I write with regards to your recent correspondence following the Inquest of Mr Roger Ginger, heard at your court in April of this year and your subsequent submission to the Chief Constable of Gloucestershire Constabulary regarding a potential recommendation for the Preventing Future Deaths report (Regulation 28 of the Coroners Investigations Regulations
2013) specifically you set out your concern that the following recommendation from our Professional Standards Department may not have been actioned: Front of House (Receptionists) to be trained on recording a VIST (Vulnerability Investigation Screening Tool) for these types of events. If a victim reports an assault but does not wish to take it further, and the staff member can see that the victim is distressed, then this could be completed to highlight that the victim is vulnerable which may trigger other support. The Chief Officer Group have met to discuss this case and wish to extend their sympathies to the family of Mr Ginger. Having considered your concern, the first point to note is that the VIST form is no longer utilised and has been replaced by a Public Protection Notice (PPN). The PPN form is a lengthy and reasonably complex questionnaire, which touches upon issues such as threats of harm, mental health and individual vulnerabilities. It is considered that it would not be reasonable nor appropriate for a Front of House Receptionist (“Receptionist(s)”) to complete these forms. This is primarily due to Receptionists often working alone and facing a high demand of attendance at police stations for other reasons. A secondary consideration is the level of skill and responsibility required for completing such a complex form - something likely to fall outside of the current role of Receptionist. To add some clarity to this decision, the document which was presented to you at court was an internal report completed by a Constable within our Professional Standards Department, who had completed the review into this sad death to determine if any of our officers had failed or breached the standards expected by the Constabulary. Whilst the Constable’s report naturally would have been reviewed by a supervisor, the recommendations within the report were never sanctioned as a strategic recommendation nor placed before our Chief Officers.

OFFICIAL OFFICIAL

Therefore, whilst the recommendation was made with best intentions, it gives no consideration to the operational impact of its implementation; neither does it consider the totality of the current economic position facing the Constabulary. Therefore, this recommendation simply is not one which the Constabulary can realistically adopt. To afford additional reassurance the Deputy Chief Constable was made aware of this example of an unsanctioned recommendation when it arose during the Inquest. As a result, a standing agenda item has been added to our Force Recommendations Improvement and Learning Board to ensure that any recommendations have sufficient strategic oversight and consideration to support meaningful implementation by the Constabulary. Setting aside the history of the recommendation itself, we recognise fully the importance of properly identifying vulnerabilities and taking safeguarding measures in circumstances such as those described in the recommendation you cited in your concern and have indeed reflected and amended our internal processes since the time of Mr Ginger’s death. In such circumstances, the current practice is now for the following steps to be taken:-
1. The Receptionist creates an Incident Log which sits on our command and control screen and, in the process, conducts a THRIVE+ assessment. THRIVE+ is a structured police assessment framework used across the country to evaluate threat, harm, risk, investigation, vulnerability, and engagement to determine the appropriate response to any incident. The assessment tool is used by police to assess the right initial response to a call for service. It places the individual needs of the victim at the centre of decision-making and allows officers and staff to judge the relative risk posed by the situation.

2. Depending on the level of safeguarding concern identified as a result of the THRIVE+ assessment, the Receptionist will seek out an officer in the station to speak with the victim or, if there is an immediate risk of harm, call an ambulance to attend to the police station. If an officer is available to speak with the victim, they will take on the Incident Log and be responsible for the welfare and vulnerability of the member of the public.

3. If an officer is not readily available, the Incident Log is sent immediately to the Force Duty Manager (FDM) in the Force Control Room, who will review the details and depending on the level of risk, either assign it to an officer for immediate attendance or add it to an incident queue for attendance in due course based on the risk factors presented. This ensures staff are deployed based on an assessment of risk.

4. Whenever attendance by an officer takes place and safeguarding concerns are present, a PPN (Public Protection Notice) will be completed, and this will trigger referrals to other non-police agencies to provide support to the victim.

OFFICIAL OFFICIAL

We acknowledge the assessments and decisions set out above are reliant on the professional judgement of the person dealing with the victim as to the perceived risk factors presented. To mitigate the risk of inconsistency and to ensure our staff are properly equipped, the Constabulary has invested in both additional vulnerability training and training provided by the College of Policing to embed the Thrive+ principles. This mandatory training package is a College of Policing online training course which our Assistant Chief Constable has mandated all officers and PCSOs and all public facing staff members to complete. This mandate has been in place since October 2023. Furthermore, all calls within the control room are also regularly dip sampled for compliance of the Thrive + principles by supervisors to ensure a further level of quality assurance. Apart from when a victim presents as unwilling to take a report further, if a victim is vulnerable and reports a crime formally then the vulnerability will also be considered along with the completion of a PPN, to ensure sufficient safeguarding has been considered. Again, these are subject to supervisory oversight to ensure quality. I hope the foregoing goes some way to reassuring you that we have indeed invested in the training in the recognition of vulnerability for our front of house staff and those officers and staff members that have public contact to proactively identify risk and ensure that appropriate measures are in place to mitigate such risk and ensure appropriate signposting and safeguarding is considered. If, of course, I can be of further assistance on this matter, please do not hesitate to contact me.

Report sections

Investigation and inquest
On 19 July 2024, I commenced an investigation into the death of Roger John  Ginger, aged 77 years. The inquest was concluded on 8 April 2026.

The jury  found that: Mr Ginger died as a result of the combined effects of hypertensive heart  disease, severe coronary artery atherosclerosis and diltiazem toxicity and that he died on 16 July 2024 at 26 Brannigan Court Northway Tewkesbury.

The conclusion of the jury as to the death: Suicide
Circumstances of the death
The deceased was found at his home address with paramedics confirming  death at the scene. The cause of death was associated at post mortem with  drug toxicity and the jury returned a conclusion of suicide. The deceased had, shortly prior to his death, been concerned about the possibility of an assault  from a third party. He had attended a local police station and spoken to a  customer contact advisor and expressed his concerns. He did not say he  wished matters to be taken further. A subsequent police enquiry concluded  (inter alia) with a recommendation.

Front of House (Receptionists) to be trained on recording a VIST (Vulnerability Investigation Screening Tool) for these types of events. If a victim reports an  assault but does not wish to take it further, and the staff member can see that  the victim is distressed, then this could be completed to highlight that the victim is vulnerable which may trigger other support.
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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Report details

Reference
2026-0218
Date of report
16 April 2026
Coroner
Ronald Wooderson
Coroner area
Gloucestershire

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: 11 Jun 2026.

Sent to

Chief Constable for the Gloucestershire Constabulary

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