Katherine Wright

I am Nicholas Graham, HM Area Coroner for Oxfordshire, c/o Oxfordshire Coroner’s Office, 1 Tidmarsh Lane, Oxford OX1 1NS

On 3 January 2024 , I commenced an investigation into the death of Katherine Wright, known as Sarah, aged 60 . The investigation concluded at the end of the inquest on 4 December 2025 . The conclusion of the inquest was a Narrative Conclusion : Sarah Wright was found deceased at her home address on 20 December 2023. She had a long-standing history of chronic alcohol misuse. Concerns for her welfare were  raised on 15 December 2023 and police attended her address on 16 December 2023 but did not locate her. She was subsequently found deceased on 20 December 2023  following a further search of her address. Post-mortem examination and toxicological  tests revealed no traumatic injuries or natural causes for her death, but tests did confirm significant alcohol levels. Her death was likely caused by sudden unexpected death in  the context of alcohol misuse. It has not been possible to determine on the evidence  when Sarah died and whether, if she had been found earlier, she would have survived.

Sarah Wright was reported missing on 15 December 2023. Thames Valley Police  officers attended her flat on 16 December 2023, forced entry, and conducted a search  but did not locate her. She was later found deceased in the same flat on 20 December  2023, during a second search. The Professional Standards investigation and evidence at the inquest confirmed that the initial search was inadequate. The officer who  undertook the bedroom search cited concerns about personal safety due to the cluttered condition of the room but did not escalate these concerns. The family were informed that a thorough search had been completed.

During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths could occur unless action is taken. The matters of concern are as follows: Lack of training and guidance for frontline officers on conducting searches of premises in missing person cases. Evidence given by the Police at the Inquest indicated that there is no structured  training or clear operational guidance on what constitutes an adequate search,  including checking all areas of a property where a person could reasonably be  found. Absence of protocols for escalating safety concerns during searches. The officer who undertook the search felt unsafe due to the cluttered  environment but did not escalate this concern or request additional resources to enable an adequate search to be carried out. There appears to be no guidance  on when and how officers should escalate such issues.

In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action.