Source · Prevention of Future Deaths
Roger Ginger
A recommendation from the Professional Standards Department, made in a report dated 9 July 2025, may not have been actioned.
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Coroner's concerns
A recommendation from the Professional Standards Department, made in a report dated 9 July 2025, may not have been actioned.
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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
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.
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
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Sent to
- Chief Constable for the Gloucestershire Constabulary