Barbara Woodman

Date of report	22 Dec 2023
Reference	2024-0100
Deceased	Barbara Woodman
Coroner	Darren Stewart
Coroner area	Surrey
Category	Alcohol, drug and medication related deaths
Source	judiciary.uk record · original PDF
Responses published	3

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS  

THIS REPORT IS BEING SENT TO: 

1. Chief Executive Officer NHS England
2. Chief Executive Officer Surrey County Council
3. Chief Constable Surrey Police
4. Chief Executive Officer Surrey and Borders Partnership NHS

Foundation Trust

1  CORONER 

I am Darren Stewart OBE, Assistant Coroner, for the Coroner Area of  
Surrey 

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 8th July 2021 I commenced an investigation into the death of Barbara 
Ann WOODMAN. The investigation concluded at the end of the inquest on 
18th October 2022. The inquest was heard without a Jury. 

Ms. Woodman died of: 
1a. Paracetamol, Codeine and Amlodipine Toxicity 

 I returned the following narrative conclusion: 

Barbara Ann WOODMAN was admitted to the Abraham Cowley Unit under 
section on the 4th of March 2021 following an overdose on the 23rd of February 
2021 which resulted in her emergency admission to Epsom General Hospital. She 
was initially guarded and did not engage with Spenser Ward staff seeking to 
provide her with care and treatment, although this subsequently improved during 
her period of inpatient care. The initial diagnosis of depression which had led to 
her section was determined inaccurate and a substitute diagnosis of personality 
disorder agreed, although additional work following her discharge was to be 
undertaken to identify the correct subcategory of personality disorder. 

Ms. WOODMAN was discharged from section on the 18th of March 2021 and 
agreed to remain at the Abraham Cowley Unit as an inpatient for a further period 
of assessment. On the 25th of March 2021 she was assessed as fit for discharge to 
the community under the care of the Community Mental Health Team. A 
telephone conversation between Ms. WOOMAN and her Care Coordinator 
occurred on the 26th of March 2021. During this call the Care Coordinator 
assessed Ms. WOODMAN as not posing an escalated risk to herself. There was 
an interaction between Ms. WOODMAN and the Police on the 27th of March 
2021 when police attended at her residence. No concerns were identified in 
relation to her risk to self except for the possible use of alcohol. A SCARF Report 
was raised by Police on the 27th of March 2021 in relation to this contact. It was 

1

 passed to the Community Mental Health Team by Surrey County Council Adult 
Social Services on the 29th of March 2021. The SCARF Report was considered by 
Ms. WOODMAN’s Care Coordinator on the morning of the 31st of March 2021. 

After several failed attempts to contact Ms. WOODMAN for a pre-arranged call 
on the 31st of March 2021, Ms. WOODMAN's Care Coordinator visited her 
residence at around 16:30 hours to ascertain her whereabouts, posting a note 
through her letterbox when she could not contact Ms. WOODMAN. Following 
discussion within the Community Mental Health Team, Police were notified of a 
concern for Ms. WOODMAN’s welfare at 18:00 hours on the 31st of March 2021. 
Police attended Ms. WOODMAN’s residence at around 19:20 hours and having 
forced entry discovered Ms. WOODMAN deceased. No notes or other evidence 
indicating that Ms. WOODMAN had intended to take her life were found. 

Post-mortem examination of Ms. WOODMAN’s body determined that she 
had died from Paracetamol, Codeine and Amlodipine toxicity. She had also 
consumed alcohol. It is not clear why Ms. WOODMAN consumed a fatal 
quantity of these drugs, and her death was drug and alcohol related. 

4  CIRCUMSTANCES OF THE DEATH 

The circumstances of the death are recorded in the Narrative Conclusion. 

5  CORONER’S CONCERNS 

Although I found there was no causal link between any act or omission on behalf 
of those involved in the care of Ms. Woodman, either from a mental health 
perspective, or by any other state agent, several matters have given me cause for 
concern.  

The MATTERS OF CONCERN are as follows: 

a. 

 evidence is that on several occasions during Ms. Woodman’s 

inpatient admission to Spenser Ward he was in communication with her and 
of which treating clinicians were aware. On at least one of those occasions 

 spoke with Spenser Ward staff. I noted that Ms. Woodman had not 

given consent for staff to contact 
Notwithstanding this, I found that there were missed opportunities to gather 
important collateral history from 
knew her well in the lead up to her admission. 

; Ms. Woodman’s partner and who 

 concerning her treatment. 

It would seem that staff speaking with 
think laterally or innovatively as to how to collect important, relevant 
collateral history whilst still respecting Ms. Woodman’s wish that her 
condition not be discussed with 

. 

 on these occasions failed to 

The ability of mental health clinicians to gain a complete picture of Ms. 
Woodman’s medical history was hampered by the fact that the information 
management systems holding these records at her GP practice was not 
accessible to secondary mental health services.  This resulted in gaps in 
information available to mental health clinicians which was not necessarily 
filled by measures taken by secondary mental health services to gather 
collateral information from the family and Ms. Woodman herself. 

2 

 
 
 
 
 
 
 
 
 b.  The handling of the Single Combined Assessment of Risk Form (SCARF) 

within the Community Mental Health Team (CMHT)  on 29th of March 2021. 
The SCARF was categorised Amber and had been received by SABP from the 
Police via Surrey County Council Adult Social Services. It concerned a 
patient on the CMHT’s books. Several witnesses gave evidence that best 
practice would involve the family of Ms. Woodman being contacted when the 
SCARF was received and considered. This did not occur. The failure to 
consider the SCARF in a more timely manner or refer the details to Ms. 
Woodman’s family is of concern; both in relation to timeliness of 
consideration and actions on receipt of the SCARF. 

c.  The care planning and recording of care plans within Ms. Woodman’s notes 
raises a further area of concern. Questions exist as to the adequacy of the 
manner in which Ms. Woodman’s care plan was recorded. It required anyone 
wishing to understand the care plan for Ms. Woodman to consult her 
SystmOne medical record and read the detailed note recorded following the 
Discharge CPA meeting on the 25th of March 2021, extrapolating from this to 
deduce the broad care plan. There was, it would seem, no single document 
that drew together multiple inputs from either MDT meetings (where risk had 
been considered), or aspects of care and crisis contingency planning (such that 
this had been considered). The result was a failure to present a holistic view of 
how Ms. Woodman’s care and risk would be managed in the community. 
Although not causative of the death and I noted 
’ very clear 
expert evidence that had a Crisis and Contingency Management Plan (CCMP) 
been in place it would have been unlikely to have averted the death, the failure 
to produce such a clear plan in accordance with Trust policies is a concern. 

d.  Multiple witnesses observed that there is frequent tension between inpatient 
staff and the CMHT in the context of decisions relating to the discharge of 
inpatients. I note the explanations provided as to why such tension exists 
given the role of each team. However, in the context of Ms. Woodman’s care, 
these tensions led to gaps and breakdowns in communication between 
inpatient and CMHT with respect to diagnosis and formulation of both the 
care plan and CCMP. 

I received further evidence in writing from the Interested Persons’ subsequent to 
the completion of the Inquest in relation to these concerns. 

This evidence included a response from Surrey and Borders Partnership NHS 
Foundation Trust (SABP) concerning the measures which have been put in place 
to address the failures identified during the course of the Inquest. 

These measures included: 

1.  The introduction of a clear discharge pathway (including risk assessment and 

care planning), with a clear role for the discharge coordinator and 
strengthening of the lead nurse involvement. 

2.  The introduction of a discrete role to liaise and engage with family (including 
where this may need to come from different family members) to collect 
collateral information relating to a patient. 

3.  The use of a mental health services multi-disciplinary team (MDT) to identify 

where possible gaps in patients previous medical history. 

3 

 
 
 
 
 
 
 
 
 
 
 4.  The introduction of measures to increase collaboration between in-patient and 

community mental health services. 

5.  The use of an SABP duty team member to monitor SCARF messages left in 

group e-mail boxes out of hours. 

I was satisfied that these measures addressed the concerns in relation to sub-
paragraphs c & d above.  I was also satisfied that the measures introduced by 
SABP in relation to sub-paragraphs a & b have addressed my concerns in relation 
to SABP’s involvement in those areas. 

However, I remained concerned in relation to the matters identified at sub-
paragraphs a & b (above). 

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:   

There is a lack of a unified record keeping system which allows the effective 
sharing of patient information between different components of the NHS, 
including primary and secondary care providers.  This results in circumstances 
where important, relevant information for the treatment of patients is not available 
to treating clinicians. 

The use of the SCARF process during out of hours to provide timely and effective 
passage of information in relation to concerns for vulnerable persons in the 
community. 

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 16th February 2024. 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. 

4 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 8  COPIES and PUBLICATION 

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

a.  Family of Barbara Ann WOODMAN 

i. 
ii. 
iii. 

 (Son) 
 (Daughter) 

 (partner of Ms. WOODMAN) 

b.  Surrey and Borders Partnership NHS Foundation Trust (SABP) 
c.  Epsom General Hospital (EGH) 
d.  Surrey County Council Adult Social Care (SCC ASC) 

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 other 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. 

9 

 22nd December 2023 

Darren Stewart OBE  

5

Responses

3 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from NHS England (PDF)

Darren Stewart OBE 
HM Coroner’s Court Surrey 
Station Approach 
Woking  
GU22 7AP 

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

4th March 2024 

Dear Coroner 

Re: Regulation 28 Report to Prevent Future Deaths – Barbara Ann Woodman 
who died on 31 March 2021.   

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  22 
December 2023 concerning the death of Barbara Ann Woodman on 31 March 2021.  
In advance of responding to the specific concerns raised in your Report, I would like 
to express my deep condolences to Barbara’s family and loved ones. NHS England 
are keen to assure the family and the coroner that the concerns raised about Barbara’s 
care have been listened to and reflected upon.   

In your Report you raised the concern that there is a lack of unified record keeping 
which  allows  for  the  effective  sharing  of  patient  information  between  different 
components of the NHS, including primary and secondary care providers.  

The National Care Records Service (NCRS)  provides a quick, secure way to access 
national  patient  information  to  improve  clinical    decision  making  and  healthcare 
outcomes  across  Integrated  Care  Services  (ICS)  boundaries.  The  NCRS  provide 
access to the Summary Care Record (SCR) which is a national database that holds 
electronic  records  of  important  patient  information  such  as  current  medication, 
allergies and details of any previous bad reactions to medicines. It is created from GP 
medical records - whenever a GP record is updated, the changes are synchronised to 
the SCR. It can be seen and used by authorised staff in other areas of the health and 
care system who are involved in the patient's direct care but do not need access to 
the patient's full record, provided that the patient has given their permission.  

The  approved  care  settings  to  view  SCRs  include  mental  health  care  settings.  The 
SCR  Team  are  also  currently  undertaking  trials  with  other  care  settings,  including 
within  private  hospitals  and  privately  funded  healthcare  services,  with  a  view  to 
working towards seeking national full roll out approval.  

Details of long-term conditions, significant medical history, or specific communications 
needs  are  now  included  by  default  for  patients  within  an  SCR,  unless  they  have 
previously told the NHS that they did not want this information to be shared. For more 
information, and to illustrate the type of content included in an SCR, an example SCR 
is available here: Additional Information in the SCR 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
  
 
 
  
 Additional Information in the SCR could include mental health conditions (e.g. bipolar 
disorder)  or  previous  psychotic  or  self-harm  episodes  where  these  have  been 
recorded in the patient’s GP record. The SCR does not contain any documents (e.g. 
a  mental  health  care  plan  or  mental  health  crisis  plan)  but  the  SCR  can  act  as  a 
signpost  to  clinicians  to  seek  further  information  from  other  teams  involved  in  a 
patient’s care.  

The  Direct  Care  APIs  programme  (formally  GP  Connect)  also  supports  care  co-
ordination both through their send document / update record capability and through 
their access record HTML and structured capabilities. Each of the services providing 
care to this patient would be expected to provide updates to the patient’s registered 
GP. Thus, the correspondence back to the patient’s registered GP and current and 
future  mechanisms  to  share  documents  /  correspondence  /  updates  from  the  GP 
record would also act to support care co-ordination for similarly vulnerable patients.  

Another  record  system  which  should  aid  the  sharing  of  health  information  between 
different organisations is the Shared Care Record. This joins up information based on 
an individual rather than an organisation and is a safe and secure way of bringing an 
individual’s separate records from different health and care organisations together.    

As of 2021, all primary and secondary care organisations have been able to share a 
subset of the patient information they hold – the core information standard – between 
providers within their own Integrated Care Board (ICB) footprint.  

There  is  now  a  target  to  achieve  national  interoperability  (read  only)  between  all 
Shared  Care  Records  in  England  by  March  2025.  This  project  will  ensure  that  any 
authorised health and care professional can have safe, secure and ready access to 
the person-based information they need to deliver high quality individual (direct) care.  

NHS England would refer you to Surrey Police, County Council and Surrey & Borders 
Partnership Trust (SABP) on your second concern relating to the use of the SCARF 
process  during  out  of  hours.  NHS  England  has  been  sighted  on  and  notes  the 
response sent to the coroner by SABP and the County Council, detailing their mental 
health crisis support services. 

I would also like to provide further assurances on national NHS England 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

Response from Surrey Police (PDF)

Response from Surrey Police to PFD (received 13.02.2024)

Dear Mr Stewart OBE,

I thank you for your regula(cid:415)on 28: Report to prevent future deaths dated 22nd December 2023. Having
reviewed its contents, I note that no speciﬁc issues were raised in rela(cid:415)on to Surrey Police. However, as 
we formed part of the inquest, I will ensure to share its ﬁndings amongst the relevant teams within the
force.

Kind Regards

Assistant Chief Constable
Surrey Police and Sussex Police

Response from Respondent Not Named (PDF)

15 February 2024 

Private and Confidential 

Mr Darren Stewart OBE 
Assistant Coroner for Surrey 
Sent by email: 

SABP NHS Foundation Trust 
18 Mole Business Park 
Randall’s Road 
Leatherhead 
KT22 7AD 

Woodhatch Place 
11 Cockshot Hill 
 Reigate 
RH2 8EF 

Dear Mr Stewart 

Barbara Woodman (deceased) 
Regulation 28 Report to Prevent Future Deaths 
Response from Surrey and Borders Partnership NHS Foundation Trust (“the Trust”) and Surrey 
County Council 

Thank you for the Regulation 28 Report to Prevent Future Deaths (PFD report) dated 22nd December 
2023,  in  relation  to  the  inquest  touching  the  death  of  Barbara  Woodman.  We  have  considered  the 
report carefully, together with senior officers within both organisations.  

In the PFD report, you highlighted a concern relating to the use of the SCARF process during out of 
hours to provide timely and effective passage of information in relation to concerns for vulnerable 
persons in the community. 

The purpose of a Single Combined Assessment of Risk Form (SCARF) is to enable Surrey Police to 
inform services where they have had contact with an adult who is considered to be vulnerable and/or 
at risk. It provides information to partner agencies and will often add to the information that the Trust 
already holds about a person. This could inform further actions that might be taken by the Trust 
which may include revisions to assessments or care plans.  

A SCARF is not designed to be used to access crisis support or as an out of hours referral tool. The 
Trust has a Crisis Line that anyone with concerns about their own mental health or someone else’s 
may use. This operates 365 days a year, 24 hours a day. In addition, there is a dedicated Professionals 
Line phone number, which also operates 365 days a year, 24 hours a day, which can be accessed by 
Surrey Police and South East Coast Ambulance Service where an urgent discussion is required. This 
allows  emergency  services  to  request  critical  information  in  an  immediate  timeframe  to  help  inform 
decisions about people they have come into contact with.  

Within Surrey County Council the Emergency Duty Team (EDT) operates out of normal office hours 7 
days a week, 365 days a year, this includes cover for all bank holidays including Christmas and New 

 Page 1 of 2 

      
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Year.  Any referrals or concerns from the police that require an immediate response there is a clear, 
well known and well used process for officers, in that they must make contact with either the Emergency 
Duty Team or nominated social worker, outside of PSPA hours.  There should be no need to use a 
SCARF and a SCARF should only be used where the situation has been left in a way that it is suitable 
for the sharing to be delayed until the next day or over the weekend.  In 2023 the EDT recorded 140 
contacts from the Police directly to them. 

We work collaboratively with partner agencies to review and improve our joint working processes. In 
relation to SCARF procedures, representatives from the Trust most recently met with Surrey County 
Council and Surrey Police on 5 February 2024 and a project group will be carrying out a detailed review 
of our cross agency SCARF process. As part of this consideration will be given as to how information 
is shared between agencies and family/carers alongside issues of confidentiality and consent.  

The Community Mental Health Recovery Services, which operate Monday to Friday, 9am to 5:00pm, 
carry  out  a  screening  process  in respect  of  SCARF forms received.  Appropriate  action  will  then be 
taken based on the information provided and the risk profile of the person this relates to.  

In relation to your concern relating to the lack of a unified record keeping system allowing sharing of 
patient information between different components of the NHS, including primary and secondary care 
providers, you have also addressed the report to the Chief Executive of NHS England who will be best 
placed to respond to this concern.  

On behalf of the Trust and Surrey County Council, we would like to offer our sincere condolences to 
Ms Woodman’s family for  their  loss. We  hope that  our  actions  outlined above  assures  you  and Ms 
Woodman’s  family  that  we  have  reflected  on  your  concerns  and  provided  reassurance  as  to  our 
processes.   

Yours sincerely, 

Chief Executive 
Surrey and Borders Partnership 
NHS Foundation Trust 

Executive Director 
Adults, Wellbeing & Health Partnerships 
Surrey County Council 

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