Source · Prevention of Future Deaths
Francis Conlin
Ref: 2026-0426
Date: 17 Aug 2026
Coroner: Paul Appleton
Area: Teesside & Hartlepool
56-day deadline: 22 Dec 2026 est. (estimated from the Judiciary.uk publication date)
Responses identified: 0 of 2
0 responses identified · 2 indexed addressees
Response deadline: 22 December 2026 (estimated from the Judiciary.uk publication date).
Coroner's concerns
Coroner’s Concerns (source excerpt)
1. Evidence provided by the PPG Head of Healthcare (“HOH”) for HMP Doncaster confirmed that a standard, national template is followed during pre-release healthcare screens. It was confirmed to me that the template is a document controlled by NHSE.
View full coroner's concerns
1. Evidence provided by the PPG Head of Healthcare (“HOH”) for HMP Doncaster confirmed that a standard, national template is followed during pre-release healthcare screens. It was confirmed to me that the template is a document controlled by NHSE. The template is understood to be the SEAT Court, Release & Transfer Out Screen (with the current version understood to be v4). The PPG HOH confirmed that the national template does not include any pre-release questions or prompts related to the mental health of the detained person who is being released. However, the nurses performing the healthcare screens are expected to consider, and if relevant ask questions about, the detainee’s mental health state. I am concerned about the absence of the above prompt/questions.
Report sections
Investigation and inquest
On 08 October 2024, I commenced an investigation into the death of Francis CONLIN, aged 23.
The investigation concluded at the end of the inquest on 12 August 2026.
The medical cause of death recorded was: 1a) Pressure on the Neck 1b) Hanging
The following narrative conclusion was recorded: Francis died due to hanging from a self-applied ligature at a time when he had consumed [REDACTED]. It has not been possible to ascertain Francis’s intention at the relevant time.
The investigation concluded at the end of the inquest on 12 August 2026.
The medical cause of death recorded was: 1a) Pressure on the Neck 1b) Hanging
The following narrative conclusion was recorded: Francis died due to hanging from a self-applied ligature at a time when he had consumed [REDACTED]. It has not been possible to ascertain Francis’s intention at the relevant time.
Circumstances of the death
Francis Conlin’s past medical history included a diagnosis of mental and behavioural disorder secondary to illicit substance misuse. It was suspected that Francis may also have had Autism; however, this was not formally diagnosed.
Francis was released from HMP Doncaster on 30 September 2024. He died on 07 October 2024 at 24 Campion Grove, Marton, Middlesbrough. Francis died due to hanging from a self-applied ligature at a time when he had consumed [REDACTED]. It has not been possible to ascertain Francis’s intention at the relevant time.
Francis was released from HMP Doncaster on 30 September 2024. He died on 07 October 2024 at 24 Campion Grove, Marton, Middlesbrough. Francis died due to hanging from a self-applied ligature at a time when he had consumed [REDACTED]. It has not been possible to ascertain Francis’s intention at the relevant time.
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.
Copies sent to
- 2. Probation Service (Ministry of Justice)
Similar PFD reports Shared signals
Responses identified
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 22 Dec 2026 (estimated from the Judiciary.uk publication date).
Sent to
- NHS England
- Practice Plus Group
Source links
Data: judiciary.uk.