“(brief summary of matters of concern) Community Mental Health Teams do not receive…”

The coroner’s concerns

(brief summary of matters of concern) Community Mental Health Teams do not receive mandatory training on the perinatal red flags that are used when assessing patients with postnatal mental health issues. The team concerned with Abigail did request training but, a year after Abigail’s death, they had not received it. They were told that an assessment had been made by those senior to them Regulation 28 – After Inquest Document Template Updated 30/07/2021 that such training is not mandatory. That women suffer poor mental health before and after giving birth is sadly common and I am concerned that there is a risk of future deaths and that a large and vulnerable group of patients will not receive appropriate care. The Perinatal Team are expert in assisting patients such as Abigail. However, they are not commissioned to complete urgent visits and must refer patients to the community mental health teams who lack the specialist training and who are likely, due to the reasons outlined above, unaware of the perinatal red flags. I am concerned that women in need will not receive the appropriate mental health care and that there is a risk of future deaths. Abigail was known to the community mental health services for just a few weeks. She had been living with her parents immediately before she died and they had attended medical appointments with her. Abigail’s parents were not spoken to by mental health professionals about their daughter’s circumstances when they would have been able to provide valuable information about her research into and planning around ending her life. It was accepted that there was a lack of professional curiosity shown by professionals both in Abigail’s case and generally and I am concerned that there is a risk of future deaths. It was accepted that there were cultural issues within the trust services. A report into Abigail’s death concluded that these included ‘a lack of professional curiosity, lack of escalations of deteriorating patients, non-patient centred decision making and a linear approach to risk assessment and formulation.’ I am concerned that there are structural issues with the leadership of the Hampshire and Isle of Wight Healthcare Trust that is to the detriment of patients like Abigail, and I am concerned about the risk of future deaths.

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

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0509

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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