Source · Prevention of Future Deaths

Roger Ginger

Ref: 2026-0218 Coroner: Ronald Wooderson Area: Gloucestershire Responses identified: 0 / 1 View PDF

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

Responses identified 0 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

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
Coroner
Ronald Wooderson
Coroner area
Gloucestershire

Responses identified

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Sent to

Chief Constable for the Gloucestershire Constabulary

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