“During the inquest, evidence was heard that: i”

The coroner’s concerns

1. During the inquest, evidence was heard that: i. There is a complex relationship between epilepsy and mental health. It is essential for there to be good communication between those working in the 2 specialities when a patient is under the care of the 2 disciplines. ii. , a Professor in Neurology at the National Hospital for Neurology and Neurosurgery, and at the University College Hospital London NHS Foundation Trust, who treats patients from across the country, confirmed that there is generally a lack of communication throughout the NHS between community psychiatric teams and neurology teams, across England and Wales. When asked if he felt that better communication would probably lead to better care and therefore prevent future deaths, he replied, "absolutely". He explained that in the past, General Practice would act as a very useful hub for communication, but in his opinion, they do not now have the time or resources to manage the communication. He explained that people with epilepsy are 4 times more likely to die by suicide and that the one thing that could be done to improve and protect lives, is better communication across the 2 disciplines. iii. , a specialist nurse in epilepsy care in Dorset, 2 explained that because of the number of patients she sees, she does not routinely look through everybody's records as she does not have the time. She explained that there are 10,000 adults in Dorset with active epilepsy and that she is 1 of 2 epilepsy nurses that cover the epilepsy nursing care across Dorset. She did not feel that there are sufficient resources to do all the things that need to be done in treating the patients. Evidence was further given that there are lengthy waiting lists for pre surgery investigations for epilepsy. Evidence was given that epilepsy services are therefore under resourced. iv. Epilepsy is a life-threatening condition. Police Officers provided evidence that they did not have training on epilepsy and mental health conditions such as post ictal psychosis, PTSD and those who have experienced sexual trauma. It is important for Police Officers dealing with people with complex needs, such as epilepsy, psychosis, PTSD and sexual trauma, to know how to deal with such individuals. Whilst it is acknowledged that Police Officers are not medically trained and should rely on medical professionals for care, having a basic understanding through training, of the behaviour of those suffering with these significant illnesses, and the impact such issues may have upon them, may assist Police Officers when dealing with, or searching for, missing persons, and therefore prevent future deaths. v. A considerable amount of evidence was heard during the Inquest around the policies and procedures in place within Dorset Police regarding concern for welfare reports, reports of missing persons and the call handling, grading and deployment of resources. It was clear from the evidence that some parts of these policies remain ambiguous or confusing. For example, in the Call Handling, Grading and Deployment Policy, there is no specific paragraph that explains that the Force Incident Manager should be notified of a high risk missing person and also wording such as ''High Risk Missing Person - immediate threat to life" can be misleading. These ambiguities could lead to wrongful application of the policy, which could lead to a future death. There is also reference to a Public Protection Notice (PPN), only being submitted once a missing person has been found and this defeats the objective of multi-agency working during the missing person search, as a PPN could yield further information from other agencies to assist in the search. vi. As well as the policies appearing to be ambiguous in places, there was evidence of confusion around interpretation of the policies and lack of knowledge of the policies within Dorset Police, especially the missing person policy. vii. During the missing person investigation by Dorset Police, and after Gaia was found deceased, there was evidence of poor record keeping, including records not being made, or when they were made not beinq sufficiently detailed and records beinq 3 retrospectively made and changed without the records being clearly marked that the entries were retrospective. Evidence was given that Police Officers learn about record keeping during their initial Police training, however, there is no evidence of further record keeping training within Dorset Police. The quality of records may impact, amongst other things, upon locating a missing person which gives rise to a risk of a future death. viii. In respect of record keeping, there have been changes made during the Inquest in the way that the Police Search Advisor (PolSA) log in Dorset Police is created, held and updated on the computer system, Niche. Evidence was given that the Lost Person Search Manager (LPSM) log has not been amended in a same way and is still being stored by Dorset Police in a similar way to which the PolSA log was being stored at the time of Gaia's death. This opens up the opportunity to amend the log, which can lead to the adding or deleting of information and could lead to records being misinterpreted. This poses a risk to the management of missing person investigations and potentially reduces the chances of locating a person alive. ix. Evidence was provided that Gaia was the victim of sexual harassment whilst an inpatient under the care of the mental health teams. Evidence was provided that such conduct can trigger a deterioration in mental health. There is no policy currently in place within Dorset Healthcare University NHS Foundation Trust (DHUFT) that deals with how staff working within the Trust should handle incidents of sexual harassment or assault. If this conduct is not dealt with appropriately this could lead to a future death. x. Evidence was given that there was a lack of communication between Gaia's family and those caring for

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, 2022-0222

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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