“There appeared to be a lack of continuity and joined-up care between those trying to…”
Dated 26 Jun 2024, from the coroner for Somerset. Sent to 3 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 21 Aug 2024.
Organisations 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.
- Report dated26 Jun 2024
- Deadline21 Aug 2024
- Published on judiciary.uk4 Jul 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Somerset NHS Foundation TrustNamed in the report as “Somerset Foundation Trust” | Response publishedPublished on judiciary.uk in July 2024. |
| National Institute for Healthcare and Clinical Excellence | Response publishedPublished on judiciary.uk in July 2024. |
| NHS England | Response publishedPublished on judiciary.uk in July 2024. |
The coroner’s concerns
– There appeared to be a lack of continuity and joined-up care between those trying to treat Mrs Moore’s menopausal symptoms and those trying to treat her mental health presentation and this suggested: (a) A lack of understanding and appreciation of the menopause and the effect this hormonal change and/or imbalance may have on women; and (b) A lack of understanding and appreciation of a potential link between menopause and a woman experiencing mental health decline. I referred in questioning to the recognised mental health conditions of Post Natal Depression (PND) and Post Natal Psychosis (PNP) where it appears to be more widely understood and appreciated amongst treating professionals that childbirth and the hormonal imbalance/upheaval can acutely affect a woman’s mental wellbeing and state of mind. However, the same awareness and/or appreciation does not appear to exist when, later in life, a woman may suffer a mental health decline due to acute hormonal changes brought about by the menopause (whether or not this is treated with HRT). There appears to be a complete absence of national and/or local guidance or published policy (none was brought to my attention on questioning of the clinicians) concerning: (a) The potential for a link between menopause and mental health decline. (b) The need for joined-up care between those trying to treat women at this stage of their lives. (c) Training and learning around hormone levels, HRT and antidepressants and the potential for a holistic approach to inform awareness and understanding.
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, 2024-0349
- Added to Minute Book
- 8 Oct 2026
- Reuse
- 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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