Source · Prevention of Future Deaths

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Ref: 2026-0245 Date: 29 Apr 2026 Coroner: James Bennett Area: Birmingham and Solihull Responses identified: 1 / 1 View PDF

NHS England guidance lacks provisions for managing staff accused of sexual misconduct, particularly regarding risk assessment, police notification, and decisions on suspension or access to fatal drugs. This means Trusts may not fully assess these risks.

Date 29 Apr 2026
56-day deadline 24 Jun 2026
Responses identified 1 of 1

Coroner's concerns

AI summary
NHS England guidance lacks provisions for managing staff accused of sexual misconduct, particularly regarding risk assessment, police notification, and decisions on suspension or access to fatal drugs. This means Trusts may not fully assess these risks.
View full coroner's concerns
1. The Trust level investigation identified concerns that NHS England guidance – e.g. (a) NHS England Misconduct Policy ‘Every organisation has a duty of care to protect its employees from and prevent incidents of sexual misconduct’; and (b) e-learning ‘Understanding Sexual Misconduct in the Workplace’ – omits to deal with how to discuss and manage the alleged perpetrator when a member of staff. It does not cover when the Trust may need to conduct a risk assessment of the likely impact on the staff member of being confronted with a serious allegation, when they may need to inform the police promptly, or advise on what factors impact the need for a prompt decision on suspension and withdrawal of easy access to fatal drugs. Since this incident the local Trust has updated their policies so that a same day decision is made on these matters and in a similar incident in the future it is likely the staff member would have been immediately suspended and had their access to fatal drugs removed. My concern is that NHS England guidance continues to omit such considerations and at a local level Trusts are not fully assessing the risks.

Responses

1 respondent
NHS England NHS / Health Body
29 Apr 2026 PDF
Action Taken

• NHS England has produced a Sexual Safety Charter outlining principles for sexual harassment prevention. • NHS England has developed a national sexual misconduct policy framework for trusts and Integrated Care Boards to adapt locally. • The national policy framework recommends that organisations establish review groups for cases with a sexual component, including risk assessments for all involved. (AI summary)

View full response
Dear Mr Bennett, Re: Regulation 28 Report to Prevent Future Deaths – who died on 8 October 2025. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 29 April 2026 concerning the death of on 8 October 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about care have been listened to and reflected upon. NHS England takes the sexual safety of staff and patients very seriously and we have produced a comprehensive suite of documents to ensure that NHS employers are taking their legal responsibilities around sexual harassment prevention seriously. These include:
• The Sexual Safety Charter – an aspirational set of principles that all NHS trusts and ICBs have signed up to;
• The national sexual misconduct policy framework – an adaptable framework for trusts and ICBs to use to develop their own local sexual misconduct policies;
• Understanding sexual misconduct in the workplace – base level training for all employees to be aware of issues surrounding sexual misconduct, disclosures and appropriate behaviours. Your Report raised concerns about whether these documents are clear enough about how to support employees who are perpetrators or alleged perpetrators of sexual harassment in the NHS. We take support for all those involved in these processes very seriously. Organisational support for these individuals is contained within the national policy framework which makes clear that support should be provided to all involved. This is done in several places within the framework:
• Under the review group section of the policy framework, it is recommended that organisations set up review groups for specially reviewing any case with a sexual component. In this section, we make clear that a risk assessment should

[Page 2] be done for all those involved which should include assessment of possible harm and where police should be contacted.
• The associated review group checklist is clear that support should be offered to all those involved and a risk assessment should be contact to support wellbeing and to reduce any further harm.
• The responsibilities for HR teams includes making clear that HR should offer support to everyone involved in a report. The national sexual misconduct policy framework makes clear that risks to individuals should be immediately assessed and steps should be taken once an allegation is reported. Steps such as suspension or removing access to fatal drugs should be considered, but these actions would not be governed specifically by a sexual misconduct policy. These decisions would typically be governed by policies relating to managing conduct (disciplinary), competence, professional standards regulations or medications management. NHS England are also taking further steps to ensure that harm arising from going through the process of an employee relations case is mitigated. We are currently reviewing the investigations training offered to every trust HR team in the country, which has a significant focus on sexual misconduct clear sections on how to reduce harm from these processes for all parties. We are also developing a national conduct and competence policy framework which will have key sections on planning support for those involved in the process and risk assessment. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of , are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Report sections

Investigation and inquest
On 21 October 2025 I commenced an investigation into the death of [REDACTED]. The investigation concluded at the end of the inquest on 2 April 2026.
Circumstances of the death
[REDACTED] had no known mental ill-health and was an experienced Operational Department Practitioner based at Birmingham Children’s Hospital. During his shift on 07/10/25 he was informed of a conduct issue. A risk assessment noted he could travel home safely and having family at home was a supportive factor. He was informed he should not come into work the following day whilst a decision was made about an investigation, and that he would be telephoned the following morning with an update. The following morning, on 08/10 around 5:30-6:00am, contrary to instructions, he attended the hospital and accessed a secure drug store and removed anaesthetic medication and intravenous cannula equipment. This was the last known sighting. From 8:45am his employer attempted to contact him via telephone without success to inform him he was to be suspended pending an investigation. Concerns were escalated around 1:30pm that he was a missing person. When it was revealed he had accessed the hospital, a search was undertaken and he was found in the afternoon deceased in a bedroom in on-call accommodation having deliberately injected himself with the anaesthetic. The medical cause of death was confirmed at post-mortem as 1a. Self-injection of [REDACTED]. The conclusion was that death was the [REDACTED] consequence of suicide.
Copies sent to
2. Birmingham Women’s and Children’s NHS Foundation Trust

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Report details

Reference
2026-0245
Date of report
29 April 2026
Coroner
James Bennett
Coroner area
Birmingham and Solihull

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: 24 Jun 2026.

Sent to

NHS England

Part of a series

10 reports
2019-0397 0 responses identified
2020-0061 All responses identified
2022-0036 1/2
2022-0095 0 responses identified
2023-0115 0 responses identified
2024-0031 All responses identified
2025-0045 All responses identified
2025-0314 All responses identified
None 1/2

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