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Steven Hart

24 Sept 2025 · Coroner Sean Cummings · Bedfordshire and Luton
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The coroner's concerns

  1. 1. ligature points in observation panels

    “Failure to Adequately Monitor and Audit Cells for Ligature Points”

  2. 2. communication breakdown of mental health risk

    “Failure to Effectively Communicate Risk and Incidents”

  3. 3. inadequate observation frequency and compliance

    “Failure to Carry Out Appropriate Observations”

Responses

2025-0487-Response-from-HM-Prison-Probation-Service-.pdf ↗

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Steven Hart · Recurance