Caroline Forte

Regulation 28: REPORT TO PREVENT FUTURE DEATHS 
NOTE:  This form is to be used after an inquest. 

REGULATION 28 REPORT TO PREVENT DEATHS 
THIS REPORT IS BEING SENT TO:  

Chief Executive Officer 
Royal College of Psychiatrists 
21 Prescott Street 
London 
E1 8BB 

1  CORONER 

I am Penelope Schofield, Senior Coroner, for the coroner area of Brighton and 
Hove.  

2  CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice 
Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 
2013. 

3 

INVESTIGATION and INQUEST 
On 21st February 2022 I commenced an investigation into the death of Caroline 
Victoria  Forte aged 35 years.  The investigation was concluded at the end of the 
Inquest on 14th March 2023. The Inquest was held with Jury. The conclusion of 
the Jury was a narrative conclusion namely: 
“Caroline Victoria Forte died as a result of suicide 
 Brighton on 
20th February 2022. She had a provisional diagnosis of severe depression with 
psychotic symptoms. Caroline was detained under Section 2 of the Mental 
Health Act. The following factors contributed to her death:- 1. Inadequate 
communication within Amberley Ward. 2. Inadequate communication between 
Amberley ward and Caroline's family. 3. No evidence of an overnight care plan 
or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 
leave of Absence policy.” 

4  CIRCUMSTANCES OF THE DEATH 

Caroline had been struggling with her mental health for some time following the 
breakdown of a relationship. Since 27th January 2022 she had been receiving 
treatment as an inpatient (under Section 2 Mental Health Act 1983) on the 
Amberley Ward at the Department of Psychiatry, Eastbourne Hospital.   On 18th 
February 2022 she was granted Section 17 weekend to take place at her 
parents address. Sadly on 20th February she was found hanging 

5  CORONER’S CONCERNS 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021 

 
 
 
 
 
 
 
 
 
 
  
 
 
 During the investigation, my inquiries revealed matters giving rise to concern. In 
my opinion there is a risk that future deaths could occur unless action is taken. 
In the circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows:- 
Ms Forte had for a number of years been seeing a private psychiatrist.  Details 
of her consultations and treatments were not made readily available to those 
working in the NHS Trusts.  It appears that there is no clear pathway for details 
of any private psychiatrist consultations to be shared with those in either the 
acute or mental health inpatient settings. The concerns are that any relevant 
history may be lost and details of any regular medication being prescribed may 
not, in a time of crisis, be immediately known.  

6  ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you 
(and/or your organisation) have the power to take such action. 

7  YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this 
report, namely by 23rd June 2023 I, the coroner, may extend the period. 

Your response must contain details of action taken or proposed to be taken, 
setting out the timetable for action. Otherwise, you must explain why no action is 
proposed. 

8  COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following 
Interested Persons: - 

The family of Caroline Forte 
Sussex Partnership Foundation Trust 

I am also under a duty to send a copy of your response to the Chief Coroner and 
all interested persons who in my opinion should receive it. 

I may also send a copy of your response to any person who I believe may find it 
useful or of interest. 

The Chief Coroner may publish either or both in a complete or redacted or 
summary form. He may send a copy of this report to any person who he 
believes may find it useful or of interest.  

You may make representations to me, the coroner, at the time of your response 
about the release or the publication of your response by the Chief Coroner. 

9 

 Dated 27th April 2023 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Penelope Schofield 
Senior Coroner, Brighton and Hove 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021

Penelope Schofield 
County Record Office,  
HM Coroner’s Office Orchard Street,  
Chichester,  
West Sussex,  
PO19 1DD 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

3 July 2023  

Dear Ms Schofield,  

Re: Regulation 28 Report to Prevent Future Deaths – Caroline Victoria Forte who 
died on 20 February 2022 

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 11 May 
2023  concerning  the  death  of  Caroline  Forte  on  20  February  2022.  In  advance  of 
responding to the specific concerns raised in your Report, I would like to express my 
deep  condolences  to  Caroline’s  family  and  loved  ones.  NHS  England  are  keen  to 
assure the family and the coroner that the concerns raised about Caroline’s care have 
been listened to and reflected upon. 

I note that Sussex Partnership NHS Foundation Trust  has written a comprehensive 
response  to  you  reviewing  the  concerns  highlighted  by  you  in  a  separate  Report 
addressed  to  them,  raising  concerns  about  Caroline’s  care.  It  is  clear  they  have 
reflected upon and taken actions and learnings from the concerns raised. I note that 
there  is  now  new  documentation  at  the  Trust;  the  ‘Record  of  patient  leaving  ward’ 
which staff complete before a patient’s Section 17 leave is approved. The completion 
of the document requires collaborative consideration of the leave safety plan with, not 
only the patient, but also any relevant family/carer/friend. If the plan lacks any detail 
this would be identified before the patient leaves the ward and should help avoid any 
reoccurrence of the issues you have highlighted regarding Caroline’s death.  

The Trust has also shared with us a helpful learning briefing on Section 17 leave from 
inpatient wards. This will be shared with the national Regulation 28 Working Group 
regional  representatives  for  dissemination  across  the  seven  NHS  regions,  to  raise 
awareness of the issue with their Trusts and to encourage best practice. 

Your concern at the lack of national guidance regarding help and support for families 
in similar situations to that experienced by Caroline’s family has also been raised with 
NHS England’s national Mental Health Team. In 2022, NHS England committed £36m 
over  three  years  to  improve  the  quality  of  mental  health,  learning  disabilities  and 
autism  inpatient  settings.  The  Mental  Health  team  have  advised  that  these 
improvements  will  include  developing  a  culture  of  care  improvement  programme 
which, importantly, is being co-produced with patients, carers, and families with lived 
experience of mental health illness. The programme, which should come to completion 
in  2025,  addresses  the  concerns  you  raise,  identifying  opportunities  to  strengthen 
family/carer voice in patient care, including the risk management of suicide and self-
harm and safety planning. This will drive forward improvements in quality and safety 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 across the board nationally, so that all patients experience excellent and meaningful 
care.  

I would also like to provide further assurances on national NHSE work taking place 
around the Reports to Prevent Future Deaths. All reports received are discussed by 
the Regulation 28 Working Group, comprising Regional Medical Directors, and other 
clinical and quality colleagues from across the regions. This ensures that key learnings 
and insights around preventable deaths are shared across the NHS at both a national 
and regional level and helps us pay close attention to any emerging trends that may 
require further review and action. 

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director

Office of the Chair & Chief Executive 
Trust Headquarters 
Swandean 
Arundel Road 
Worthing 
West Sussex 
BN13 3EP 

29 June 2023 

Dear Ms Schofield  

Inquest into the Death of Caroline Forte - Letter of Concern 

Thank you for your letter dated 5 May 2023, addressed to my predecessor, 

. 

I was sorry to learn of the concerns relating to the Serious Incident (SI) investigation into Caroline's 

death and I'm grateful to you for affording the Trust the opportunity to review matters and provide 

you with this response.  I understand that this response, along with the  letter I sent you last week, 

responding to the Regulation 28 Report, will be shared with Caroline's family.  As such, I would also 

like to extend, through this letter, my sincere apologises to them regarding the quality of the Trust's 

SI report. I am truly sorry that it did not fully consider all matters relating to Caroline's death and thus 

enable  the  comprehensive  learning  that  should  have  happened  following  Caroline's  death.    I 

sincerely  hope  this  this  letter,  coupled  with  the  response  to  the  Regulation  28  report,  provides 

assurance. 

I  understand  that,  during  the  Inquest,  three  areas  of  concern  regarding the  quality of  the  SI  arose, 

namely, that the: 

1. SI investigation did not identify the four issues that the Jury found contributed to Caroline's

death and, indeed, found that 'all care provided was responsive and appropriate';

2. SI reviewer did not record or consider, within the SI, the important issue of Caroline ligature

tying on the ward; and

Head office: Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP 

www.sussexpartnership.nhs.uk 

A teaching trust of Brighton and Sussex Medical School 

 
 
 
 3. 

'Lessons learnt' were not captured within an action plan, so there was no evidence that they 

were actually actioned. 

I  am  particularly  disappointed  to  read  of  these  concerns  as,  when  I  first  joined  the  Trust,  as  Chief 

Nurse, nearly 2 years ago now, I quickly recognised that our internal incident investigation processes 

required  improvements.    That  being  said,  any  significant  change,  of  course,  takes  time  and  I 

recognise that the SI report into Caroline's death was completed in August 2022. The improvements 

specific to the SI investigation process have been taking place over the course of the last 18 months 

and have led to the Trust's central investigation team undergoing significant and ongoing change. A 

number of senior personnel changes, coupled with the need to prepare for the forthcoming national 

change from the SI framework to the Patient Safety Incident Response Framework (PSIRF) has meant 

that  the  SI  team  has  required  significant  support  to  enable  the  necessary  changes  to  occur,  whilst 

also continuing to operate.  Whilst this does not in any way excuse any SI's being below the standard 

we  expect,  and  the  SI  into  Caroline's  death  was  certainly  below  that  standard,  I  feel  the 

aforementioned  context  is  important  to  share  with  you  to  enable  me  to  provide  you  with  the 

assurances  you,  and  Caroline's  family,  understandably,  seek  as  to  the  quality  of  other  and  future 

SI/PSII reports. 

Turning  to  your  specific  concerns,  I  will  address  the  first  two  concerns  jointly  as  they  relate  to  the 

intrinsic quality of the SI review itself.  The most significant change the Trust has made since last year 

is the way in which SI reports are quality assured. Specifically, now, SIs are subject to a higher  level 

and layered quality review process, including, ultimately, sign-off by either the Trust's Chief Nursing 

Officer  or  the  Chief  Medical  Officer.    Additionally,  multi-disciplinary  panel  sign-off  approaches  are 

now used so that quality can be assessed and discussed with the benefit of a range of expertise to 

provider richer scrutiny and thus learning.  This multi-disciplinary/panel approach is also now being 

used  during  earlier  stages  of  investigations  by  the  use  of  subject-matter  experts,  in  more  complex 

cases, as well as wider use of independent chairs.  These new wider multi-disciplinary approaches are 

also key as the Trust transitions to PSIRF. 

Page 2 of 4 

 
 
 
 
 
 PSIRF  provides  the  Trust  with  a  clear  and  welcome  opportunity  to  affect  the  nationally  recognised 

need to change from the SI framework to a more effective model of responding to incidents.  So, this 

is where the Trust has invested in and is focusing upon, to ensure we have robust processes in place 

to  sustain  meaningful  improvements  to  the  way  we  respond  to  incidents.    The  Trust  is  aiming  to 

transition to PSIRF at the end of August 2023.  Prior to that transitioning the Trust's Legal Director 

would  welcome  the  opportunity  to  meet  with  you  to  discuss  the  transition  and  the  Trust's  key 

priorities  for  future  investigations,  to  ensure  that  they  are  in  line  with  those  matters  that  you  feel 

ought to be prioritised in the forthcoming year.  I understand that the Legal Director has a planned 

meeting  with  you,  on  other  matters,  in  a  few  weeks'  time,  and  I  will  ask  that  she  takes  the 

opportunity to initiate the conversation with you in relation to PSIRF. 

Regarding your third concern, I confirm that, earlier this year, the SI team adapted their processes to 

enhance the 'lessons learnt' section, within all SI reports, to seek to widen the scope, for capturing 

learning.  It  is  right  to  say  that,  initially,  this  learning,  particularly  if  already  effected,  did  not  always 

have  an  action  plan.    However,  since  our  new  Chief  Nursing  Officer  has  been  overseeing  SIs,  all 

'lessons learnt' have had a corresponding action within a monitored action plan.  I can also confirm 

that  all  action  plans  are  overseen  by  the  central  SI  team  and  their  monitoring  feeds  into  the 

governance  structures  within  the  clinical  directorates,  who  are  then  responsible  for  ensuring 

completion of the actions. We have a newly established Quality and Risk Management Committee, 

co-chaired by the Chief Medical Officer and Chief Nursing officer, where assurance and risks relating 

to the learning from SIs and the action plans are overseen.  

I  hope  that  the  aforementioned  actions  are  of  assurance  to  you.  We  believe  that  the  current 

Executive  led  governance  of  SI  reports,  followed  by  the  implementation  of  PSIRF  has  and  will 

continue to lead to sustainable improvements in the quality of the learning we extract from SIs, to 

reduce incident recurrence and thus improve patient safety.  As indicated, this is an ongoing piece of 

work, with national change being implemented, and the Trust welcomes your involvement.  We will, 

of  course,  continue  to  monitor  both  the  effectiveness  of  the  recent  improvements  and  how  we 

achieve  the  best  future  improvements,  as  we  transition  to  PSIRF.    I  will  add  an  update  on  the 

Page 3 of 4 

 
 
 
 
 transition  when  I  write  to  you  in  6  months'  time  to  update  you  on  the  Regulation  28  related 

improvements.  In the meantime, if you have any questions regarding the content of this response or 

if I can further assist please do not hesitate to contact me. 

Yours sincerely,  

Chief Executive Officer 

Sussex Partnership NHS Foundation Trust  

Page 4 of 4

Office of the Chair & Chief Executive 
Trust Headquarters 
Swandean 
Arundel Road 
Worthing 
West Sussex 
BN13 3EP 

Thursday 22 June 2023 

Dear Ms Schofield  

Inquest into the Death of Caroline Forte, Regulation 28: Report to Prevent Future Deaths 

I write in response to your Regulation 28 Report dated 27 April 2023, addressed to my predecessor, 

I was so sorry to read the details of the circumstances leading to Caroline's death and I extend my 

sincerest condolences to her family. 

I  acknowledge  and  understand  the  concerns  that  you  have  raised  and  want  to  assure  you  that, 

following  the  Inquest,  the  Trust  took  immediate  steps  to  seek  to  learn  from  the  Inquest's  findings 

and make improvements, not just specifically relating to Amberley ward but trust-wide.  

To do that, the Trust set up a working Group, of senior clinicians, to identify what action was needed 

to prevent recurrence of the contributory factors identified in Caroline's Inquest.  That working Group 

was  led  by  the  Trust's  Deputy  Chief  Nurse  (Quality,  Safety  &  Improvement)  and  met  fortnightly  to 

formulate  the  necessary  improvements  and  enable  trust-wide  implementation.    Additionally,  in 

parallel,  the  Trust's  Legal  Director  led a  piece of  work  to  create  new  leave  documentation,  process 

and policy.  I will describe the outcomes of the improvements in turn, utilising and thus responding 

to each of the seven concerns you raise in your Regulation 28 Report: 

Head office: Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP 

www.sussexpartnership.nhs.uk 

A teaching trust of Brighton and Sussex Medical School 

 
 
 
 
 a)  The daily care log was not completed so it was not possible to ascertain who was the last 

person to see Caroline leave the ward 

During  the  aforementioned  improvement  works,  it  was  recognised  that  the  existing  'log'  did  not 

sufficiently enable staff to be prompted and to capture all relevant information, and needed improving 

in a number of areas.  So, new documentation has now been created, in the form of a new 'Record of 

patient leaving ward' document, a copy of which I attach. This will be introduced on the Trust's wards 

from 1 July, with local training being provided to staff to ensure the importance of it's consistent use is 

fully  understood.  As  with  any  new  documentation  there  will  then  be  a  review  of  the  new 

documentation's  efficacy;  this  will  be  done  in  3 months'  time  and  the  findings  reported  through  the 

Trust's Acute Care Forum.  That Forum is a meeting of trust-wide clinicians as well as service users, and 

the  new  documentation  was  collaboratively  formulated  within  that  Forum  to  seek  to  ensure  that  it 

would best meet the needs of staff, patients and families/carers.    

b)  There was no record to show which nurse carried out a risk assessment before she left 

The new 'Record of patient leaving ward' document requires a Registered Nurse (or another registered 

professional,  such  as  Medic  or  OT)  to  sign  the  patient  out.    Moreover,  and  specifically,  the  new 

document makes it clear that, by signing the form, the nurse/medic/OT has collaboratively considered 

the  patient's  leave  safety  plan  with  them  and  any  relevant  family/carer/friend  etc  and,  furthermore, 

that the leave safety-plan has been collaboratively re-affirmed by all. 

c)  There was no overnight care plan 

As  referred  to  above,  completion  of  the  new  'Record  of  patient  leaving  ward'  document  requires 

consideration of the leave safety plan which, if a patient were going on overnight leave, would require 

consideration  of  the  overnight  care  plan  and  would  thus  identify  if  it  were  missing.    Overnight  care 

plans are used by Amberley ward, as a local initiative, and the ward Matron is now doing monthly spot 

checks to confirm that these are being completed and uploaded for patients going on overnight leave.  

Further, the Trust has an ongoing trust-wide audit programme whereby it is qualitatively auditing in-

Page 2 of 5 

 
 
 
 
 patient  records  to  ensure  care  plans  are  appropriately  completed.  This  audit,  once  complete,  will  be 

presented  to  and  monitored  by  the  Trust's  Effectiveness  Committee,  to  ensure  care  plans  are  of  an 

appropriate standard trust-wide. 

d)  The “My care and safety plan” had not been updated with regards to “My family will do” 

section 

As  referred  to  above,  completion  of  the  new  'Record  of  patient  leaving  ward'  document  requires 

collaborative  consideration  of  the  leave  safety  plan  with,  not  only  the  patient,  but  also  any  relevant 

family/carer/friend  etc.    So,  any  lack  of  detail  in  the  'My  care  and  safety  plan'  would  be  identified 

before a patient were permitted to leave the ward.   

e)  The family were not provided with a copy of the Section 17 leave form  

When the new 'Record of patient leaving ward' document is completed there is now a specific prompt 

to  ensure  that  the  patient  (if  detained)  has  a  copy  of  the  s.17  leave  form  then  there  is  the 

aforementioned  collaborative  consideration  of  the  leave  safety  plan  with  the  patient  and  the 

family/carer/friend etc.  This will enable family/carer/friend etc to have knowledge of the contents of 

both  the  s.17  leave  form  and  the  safety  plan.    That  collaborative  conversation  would  enable  further 

documents to be copied and provided, as appropriate.   

f)  At the time of this leave the family were unaware that Caroline had self-harmed in the 

hospital by tying a ligature. Therefore, the family told the Inquest that they therefore 

had no strategies in place to minimise the risks of such an event. Similarly, there was no 

communication with the hospital as to how to minimise Caroline’s risk.  

As indicated above, safety planning ought to be a collaborative process and I was truly saddened to 

hear  that  Caroline's  family  were  left  without  strategies  to  support  them  to  minimise  Caroline's  risks.  

Amberley ward have, of course, reflected, at length, on the sequence of events that led to Caroline's 

death.  The Matron is overseeing monthly audits to check that family have either participated in ward 

Page 3 of 5 

 
 
 
 
 
 reviews, or been contacted after, to be given an update.  The ward's aim is to invite a relevant family 

member to their loved ones' MDT review meetings, so the family member can participate in the review 

and have an opportunity to give their own views. If they have not been able to attend then a call to the 

relevant family member is made after the meeting to ensure they are aware of the plan. Additionally, 

the ward is considering employing a "Carers Lead", who would provide a primary point of contact for 

all  family  members.    Further,  the  aforementioned  trust-wide  care  plan  and  risk  assessment  auditing 

includes qualitatively auditing to ensure meaningful, appropriate family/carer engagement, as part of 

the  Trust's  ongoing  2023/4  improvement  plan.      The  new  'Record  of  patient  leaving  ward'  document 

will also ensure a further collaborative conversation takes place and the leave safety plan is re-affirmed 

before the patient leaves the hospital. 

g)  Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 

leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk 

Management Police and Procedure.  

The  s.17  leave  policy  is  being  updated,  so  that  it  incorporates  the  new  form,  as  well  as  some  other 

modifications.    Once  ratified,  there  will  be  corresponding  training  which  is  delivered  by  the  Trust's 

Mental  Health  Act  team  which  is  overseen  by  the  Trust's  Legal  Director.  Regarding,  the  ward's 

understanding of the Safe and Effective Assessment & Management of Clinical risk: Risk Management 

policy,  I  understand  that  this  specifically  centred  on  the  aforementioned  assessment  of  risk  prior  to 

s.17  leave  and  corresponding  sharing  of  information  within  the  ward  and  with  the  family.    The 

Amberley  ward  Matron  led  the  ward's  discussions  about  the  improvements  needed  following  the 

Inquest  which,  in  addition  to  those  already  mentioned,  has  involved  on-going  monitoring  of  the 

quality of concise and precise handover of information (both verbal and written) from shift to shift, and 

to MDT, during MDT daily handovers.  Additionally, the Matron has been working with the Trust's lead 

trainer  for  clinical  risk  and  the  Trust's  suicide  prevention  lead,  to  fully  understand  early  indicators  of 

risk to ensure his ward is capturing and fully understanding these warning signs.  The Matron has also 

been actively involved in the formulation of the new 'Record of patient leaving ward' document which 

Amberley ward will be using from the trust-wide implementation date of 1 July. 

Page 4 of 5 

 
 
 
 By way of further assurance, and for completeness, I have also enclosed the Patient Safety Learning 

briefing that the Trust circulated, following the Inquest, to all its acute care teams, for learning from 

the matters that arose in the Inquest. 

I hope that the aforementioned actions are of assurance to you. We believe that these actions will 

lead to a substantial improvement in the experience of patients and the families/carers/friends who 

support  them  when  they  are  on  leave  from  our  hospitals.    As  indicated,  we  will  be  monitoring  the 

effectiveness  of  these  improvements  to  ensure  they  meet  the  needs  of  our  patients  and  their 

families/carers/friends and will write to you with an update in 6 months' time.  In the meantime, if 

you have any questions regarding the content of this response or if I can further assist please do not 

hesitate to contact me. 

Yours sincerely,  

Chief Executive Officer 

Sussex Partnership NHS Foundation Trust  

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