“(brief summary of matters of concern) 1”

The coroner’s concerns

(brief summary of matters of concern) 1. I am concerned that Naomi was never seen face to face by her care coordinator over the 3 – 4 month period that she was under the care of the CMHT. I heard evidence that the Andover CMHT, in particular, was impacted by a Regulation 28 – After Inquest Document Template Updated 30/07/2021 change in the way that primary care networks (PCNs) refer patients to secondary services. Due to Naomi’s GP surgery being within a particular PCN she was referred to the Andover CMHT even though she lived in Four Marks, a 40-50 minute drive from Andover. This is much further than would have been the case had Naomi come under the care of the Winchester CMHT. The Andover CMHT has not been able to arrange as many face to face appointments with care co-ordinators due to the time they would have to spend travelling. Naomi’s care was not referred to the Winchester CMHT originally nor was it transferred from the Andover to the Winchester CMHT after the referral was accepted. 2. I am concerned that within the Andover CMHT the training around risk assessments and the auditing of compliance with risk assessment policy is not adequate. In relation to Naomi I heard evidence that the completion of formal risk assessments was not carried out in accordance with the CMHT policy. I heard evidence that Andover CMHT had undergone risk assessment training at around the time they were involved in Naomi’s care. Despite this no formal risk assessments were completed. In addition I heard that the process for auditing risk assessment compliance had not identified this failure in respect of Naomi’s care. I also heard evidence that the Andover CMHT had requested further training from the Hampshire and Isle of Wight Trust but that this had not taken place. 3. I am concerned that the Andover CMHT do not appear to have considered how to keep a person’s family involved in their care (when there is the appropriate consent to do so) when meetings with the care co-ordinator take place over the phone and not face to face.

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, 2025-0522

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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