“It became very clear in evidence that the overseas involvement was not properly flagged…”
Dated 2 Mar 2020, from the coroner for Hampshire (Central). Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
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Report put online after its 56 daysOrganisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
judiciary.uk put this report online on 1 Oct 2020, after the 56 days for replies had ended (27 Apr 2020). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated2 Mar 2020
- Deadline27 Apr 2020
- Published on judiciary.uk1 Oct 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Berkshire Healthcare NHS Foundation Trust | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
It became very clear in evidence that the overseas involvement was not properly flagged up when the CPE came to triage Sophie's referral; this includes both the discharge summary and Sophie's own self-referral via email whilst she was in Australia. The full discharge summary from Australia was sent by the GP along with his referral on the 8th May 2019 to ensure that all relevant information was shared at the earliest stage. These notes were either not fully reviewed and/or understood by the CPE and this appears to have contributed to the downgrading of Sophie's referral. It became clear in evidence that the UK services did not understand that "Scheduled" is the Australian equivalent of being "Sectioned" and there was a lack of probity and curiosity to as what this meant and what treatment Sophie had in Australia; albeit that the evidence was not convincing (or even persuasive) that the Australian discharge summary had been thoroughly read at all on being received by the CPE . Overall, there appears, on the evidence, to be very poor communication between the departmental services and, as a result, opportunities appear to have been missed to fully appreciate Sophie's full clinical presentation when making an assessment about the timeliness of appropriate interventions and assessments. I believe that whilst the service remains disjointed, with insufficient exploration of information sent from foreign jurisdictions, there remains a risk that future death will continue to occur.
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, 2020-0142
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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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
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