“Part 1 (1) Anne was not sent home for her first overnight leave with any codified ‘Risk’…”

The coroner’s concerns

– Part 1 (1) Anne was not sent home for her first overnight leave with any codified ‘Risk’ and ‘Safety Planning’ document. Whilst it was widely accepted in this case that Anne’s husband was well versed and knowledgeable about his wife’s risks and the measures that might be necessary to help keep her safe whilst she was at home, not all families are as involved in their loved one’s psychiatric care, despite the Trust following the Triangle of Care principles. Whilst families are not mental health practitioners and are not expected to adopt that role within the community there appears to be an opportunity to supply families with a short, codified document dealing with salient points of risks and safety planning when a patient goes for their first overnight leave since being detained. This may equip families with the knowledge to spot signs of declining mental presentation and/or risk and provide them with the knowledge and/or tools to take appropriate steps to assist in safeguarding their loved ones whilst they are in the community. This concern (and any action deemed appropriate by the recipients of this PFD) is not intended to override autonomy of the patient and their own ability/responsibility to keep themselves safe, but the concern centres around their being an opportunity to assist families in spotting early warning signs that ‘something is wrong’ and to seek help and intervention (if/when appropriate) to minimise the risk of a patient taking their own life whilst in the community. (2) It transpired during the Inquest that if an in-patient (detained or voluntary) accesses the secure unit Wi-Fi there are no algorithms or ‘search detection features’ to prevent access to websites pertaining to self harm and so these can be readily accessed by a group who are already vulnerable due to their acute mental health presentation with some element of inherent risk of suicide. It was noted, quite rightly, by legal representatives that workplace organisations can block access to certain sites they deem it undesirable for their workforce to access (such as sites relating to gambling, sexually inappropriate content etc) which shows that it is possible to limit access to certain websites and content when using a Wi-Fi provider. By allowing an already vulnerable group to have unfettered access to websites dedicated to self harm creates a risk of further deaths. Part 2 (3) I am (and remain, having previously issued a PFD in a similar vain on the 26th June 2024) concerned about the lack of ‘importance’ given to menopausal care available to women on the NHS; especially when compared to private sector meaning that women who are not fortunate enough to be able to access private clinics and facilities may not be able to access the services and expertise they need at a very crucial transitional phase in their lives. Menopause is not a lifestyle choice, it is an unavoidable part of a woman’s natural biological cycle. Without wishing to introduce sweeping generalisations, menopause is likely to affect 50% of the population at some point in their lives [according to Statistics Times, women made up 50.75% of the UK population in 2024]. I am concerned that: (i) Certain elements of medicine and clinical practice training are compulsory but having heard evidence at the Inquest around mandatory and statutory 4 training modules I learnt that this covers areas such as GDPR training and disposal of sharp objects such as syringes. I was surprised to learn that menopausal training is not mandatory in any area of clinical practice or specialism. I am concerned that there is no requirement to undertake essential compulsory menopausal training for those working in ‘relevant’ clinical practices such as Mental Health Practice, Obstetrics and Gynaecology and Oncology, or even general as a general GP. (ii) I was told that the Trust has just one ‘menopause specialist’ (a GP) who covers the entire Trust operations. Not all GP surgeries have a menopause specialist practitioner (or access to one) despite a GP usually being the first port of call for women in the community when seeking primary care. Those GP Surgeries who do have a practitioner who acts as a ‘specialist’ is often a GP with a personal interest who has taken the initiative to go on courses and broaden their learning and understanding, rather than any mandatory requirement for a Surgery [or group with multiple surgeries] to have an available community ‘front-line’ specialist. I was told that the Trust does not have an “expert” in this field and it would be difficult to have one as menopause isn’t a disease or an illness. Whilst I do not dispute that is it not a disease, menopause is a condition; it does have symptoms and it does have recognised presentations, yet there appears to be a failure to recognise this condition as having equal importance to other ailments or diagnoses. I was told during a previous PFD Response relating to menopausal knowledge and care within the NHS that “It is important to ensure that women understand common symptoms such as anxiety, stress and depression which they might experience during the menopause and where and when to seek help. The NHS website has resources….” This emphasises my concerns entirely; the lack of importance given to menopausal symptoms. If someone has concerns about heart disease, a worrying lump, a broken bone etc they expect to be able to consult a medically qualified professional who has a knowledge and understanding of their condition or presentation and can diagnose and treat accordingly; not just [and I paraphrase] ‘have a look at a website to help’. I appreciate that each and every woman will experience perimenopause and menopause differently, their individual experience is unique to them and this, to some degree, creates difficulties as a ‘one size fits all’ approach (which is perhaps achievable in other medical specialisms and disciplines) cannot be offered, but the lack of recognition of th

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

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judiciary.uk, Prevention of Future Deaths reports, 2025-0200

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0