“Rianna had a long history of dangerous self-harming behaviour and a diagnosis of…”

The coroner’s concerns

Rianna had a long history of dangerous self-harming behaviour and a diagnosis of Emotionally Unstable Personality Disorder. On 4th January 2025, she self-ligated , which had been provided for her by a member of staff at Beech Ward, Sherwood Oaks Hospital, Mansfield, However, whilst unobserved in her room, . She had done this on several previous occasions in the preceding eight weeks but had always been interrupted. The ease with which a) t and b) the complete absence of any system for controlling a vulnerable patient's access to material which can easily be adapted for self-harming purposes, is a real concern. The staff gave evidence to the effect that they had no other available to give patients. 11. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: [please do not use individual’s names, but instead roles/titles]   NHS England Mother of Rianna   Father of Rianna Nottinghamshire Healthcare Trust - NHCT I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. 12. SIGNATURE Simon BURGE Assistant Coroner for Nottingham City and Nottinghamshire

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, 2026-0357

Added to Minute Book

7 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