Michelle Moore

Ms Samantha Marsh 
Senior Coroner 
Somerset Coroner’s Service 
Old Municipal Buildings 
Corporation Street 
Taunton 
Somerset  
TA1 4AQ  

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

26/09/2024 

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Michelle Patricia Moore 
who died on 31 October 2023.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  26 
June 2024 concerning the death of  Michelle Patricia Moore on 31 October 2023. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Michelle’s family and loved ones. NHS England are 
keen to assure the family and the Coroner that the concerns raised about Michelle’s 
care have been listened to and reflected upon.   

I am grateful for the further time granted to respond to your Report, and I apologise for 
any  anguish  this  delay  may  have  caused  Michelle’s  family  or  friends.  I  realise  that 
responses to Coroner’s Reports can form part of the important process of family and 
friends coming to terms with what has happened to their loved ones, and I appreciate 
this will have been an incredibly difficult time for them. 

Your Report raises concerns over the lack of understanding and appreciation of the 
potential link between menopause and mental health decline, the need for joined up 
care and associated training and learning.  

It is acknowledged that mental health problems can decline in women of menopausal 
age.  There  are  often  biological,  social  and  psychological  reasons  why  women  may 
experience mental health problems at this stage in their lives. Changes in hormones 
during the menopause can cause existing mental health problems to worsen or can 
cause  women to experience  symptoms  afresh.  This means that  women often  need 
some  help  with  their  mental  health  as  well  as  their  physical  health  during  the 
menopause. However, women are not universally or uniformly at risk of psychological 
symptoms over the menopause transition.  

It is important to ensure that women understand common symptoms such as anxiety, 
stress and depression which they might experience during the menopause and where 
and when to seek help. The NHS website has resources which help to guide women 
in terms of what to expect and where to seek help: Menopause - Symptoms  - NHS 
(www.nhs.uk).  This  includes  information  on  the  mood  changes  that  women  may 
experience in menopause and the potential benefits of HRT. There is also a ‘help and 

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
 
  
 support’ page which provides some clinical advice along with the details of charities 
that are able to offer further information and support. It is, however, acknowledged that 
Michelle  had  multiple  contacts  with  healthcare  professionals,  particularly  between 
January  2023  and  October  2023,  and  had  raised  concerns  about  menopausal  / 
perimenopausal symptoms, and she could not identify any specific event, trigger or 
stressor for the decline in her mental health in the 18 months prior to her death.  

NHS  England  is  currently  supporting  the  development  of  a  range  of  tools  and 
interventions that will help to upskill more GPs in providing menopause care, and to 
improve access to treatments that can be helpful. GPs are well placed to take a holistic 
approach to mental health assessment, including menopause as one of the potential 
causes of mental distress or a decline in mental health.   

Women’s health hubs are in the process of being rolled out, which will offer specialist 
menopause care to more women when they need it. A toolkit that supports local areas 
to  provide  menopause  information,  events  and  group  consultations  is  also  under 
development to improve access and provide a forum for learning for other healthcare 
professionals.  

Existing  NHS  Talking  Therapies,  like  cognitive  behavioural  therapy  (CBT),  or 
counselling can be used to help patients who experience depression or anxiety linked 
to  menopause  and  perimenopause.  NHS  Talking  Therapies  operates  a  ‘hub  and 
spoke’ model, which typically includes a central management and administration office 
with strong primary care and community links, that enables treatment to be provide in 
local settings that are as easy for people to access as possible (such as GP practices, 
community settings and voluntary organisations).  

Your  Report  also  raised  concerns  about  a  lack  of  national  guidance  regarding  the 
issues of menopause and mental health decline. I am aware that your Report has also 
been  sent  to  the  National  Institute  for  Health  and  Care  Excellence  (NICE)  and  the 
Somerset  NHS  Foundation  Trust.  I  have  not  yet  had  sight  of  their  responses,  but  I 
would  like  to  refer  you  to  the  NICE  guidance  on  menopause  diagnosis  and 
management  [NICE  guideline  NG23],  which  was  published  on  12  November  2015. 
This  guideline  recommends  it  is  explained  to  women  that  they  may  experience  a 
variety of symptoms associated with menopause, including low mood or anxiety, and 
sets out some of the available treatments, including HRT and cognitive behavioural 
therapy.  NICE  will  be  best  placed  to  provide  you  with  further  information  around 
national guidance. 

I  would  also  like  to  provide  further  assurances  on  the  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  events,  such  as  the  sad  death  of 
Michelle, are shared across the NHS at both a national and regional level and helps 
us to 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

2nd Floor 
2 Redmond Place 
London 
E20 1JQ 
United Kingdom 

29 August 2024 

Ms Samantha Marsh 
Senior Coroner for Somerset 
Somerset Coroners Service 
Old Municipal Buildings 
Corporation Street 
Taunton 
Somerset  
TA1 4AQ 

Sent via email: 

Your ref: 
Our ref: 

Dear Ms Marsh, 

I write in response to your regulation 28 report, dated 26 June 2024, regarding the very sad 
death of Michelle Patricia Moore. I would like to express my sincere condolences to Mrs 
Moore’s family.  

We have reflected on the circumstances surrounding Mrs Moore’s death and the concerns 
raised in your report.  

In March 2023, we received a Healthcare Safety Investigation Branch (HSIB) safety 
recommendation asking NICE to evaluate the available research relating to the risks 
associated with menopause on mental health and if appropriate, update existing guidance.  

In response to this recommendation we began an exceptional surveillance review of our 
clinical guideline to see if an update to our recommendations was required.  

An independent committee is currently updating our guideline on menopause: diagnosis and 
management [NG23]. We expect to publish the updated guideline on 7 November 2024. 

Following publication, our surveillance team will assess if any further changes relating to 
mental health and menopause are needed, in response to the HSIB recommendation and 
taking into account the issues raised in your report.  

Your report has been shared with the surveillance team who will carry out this work. 

Please do let me know if you require any further information and again, I offer my sincerest 
condolences to Mrs Moore’s family.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Yours sincerely, 

Chief Executive 

                                                                                                                                 Page | 2

26 September 2024 

Mrs Samantha Marsh 
c/o Taunton Coroners Court 

Sent via email to  

Dear Mrs Marsh 

Trust Management Office
Musgrove Park Hospital

Barton House South  

Parkfield Drive
Taunton
TA1 5DA

REGULATION 28 REPORT – PREVENTION OF FUTURE DEATHS – Michelle Moore 

I am writing in response to your correspondence dated 26 June 2024 regarding the regulation 
28 of the Coroner’s (investigations) Regulations 2013 following the inquest regarding the death 
of Michelle Moore which concluded on 25 June 2024.  

We have set out the matters of concern as raised in the report and our response to them.  

MATTERS OF CONCERN 

1.  A lack of understanding and appreciation of the menopause and the effect this hormonal 

change and/or imbalance may have on women. 

2.  A lack of understanding and appreciation of a potential link between menopause and a 

woman experiencing mental health decline 

As the Coroner has respectively acknowledged there is no national guidance on the potential 
link between menopause and mental health decline. Within the Trust we have taken steps to 
address the concerns that were raised and to build on work that was already underway across 
both our Mental Health and Learning Disabilities Service Group and the wider organisation. 

Clinicians in psychiatric services can access the online training offered by the Royal College of 
Psychiatrists and this was referred to at the inquest by our consultant witness who has 
undertaken the training. This resource is available to all our psychiatry colleagues and will be 
included in the guide that is being prepared, please see below.  

Somerset NHS Foundation Trust (SFT) is responsible for the provision of care within  16 GP 
practices across Somerset. Our Director for Primary Care, who is also a GP and menopause 
specialist, has been leading training on the menopause for both GP’s and clinicians in mental 
health since the beginning of the year. This has enabled us to deliver bespoke training for 
colleagues and there is more arranged specifically for the Learning Disability team and Mental 
Health, as well as physical health colleagues. To support the integration with other GP practices 
outside of the Trust our Director for Primary Care works closely with our Medical Director of 
Integrated and Primary Care to determine if we can offer training/sharing of information more 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 widely. For patients where Mental Health colleagues are concerned, there is the opportunity to 
contact practices directly and liaise with the menopause specialist in that practice around 
menopause management or to contact the NHS Somerset Menopause service.  

Within the Mental Health and Learning Disability Service Group a Task and Finish group has 
been established to look further at this concern. It is a multi-disciplinary group and has been 
meeting for the last few months to determine how best we can share information with 
colleagues. The initial plan is to share with colleagues’ guidance on considering 
menopause/perimenopause when assessing this patient group. Key themes to consider will be: 
1.  Considering perimenopause and menopause as part of assessment – remember to ask 
the question, and we are establishing if there is potential to put a prompt in Dialog+ 

2.  Adequate knowledge of both physical and non-physical signs of menopause and 

perimenopause. It is not expected that mental health clinicians will make the primary 
diagnosis, but it should be on the list of considerations for patients who meet these 
criteria, with a clear onward referral to their GP if required.  

3.  Consideration of what Mental Health and menopausal symptoms might look like. 

Awareness of potential for overshadowing, need to establish a proper history from the 
patient. This is supported by the training offered by the Royal College of Psychiatrists 
and internal training.  

4.  Screening and signposting to other services and websites where help is available 

These points are relevant to both inpatient and community services, and the guidance will be 
shared within the coming weeks.  

In addition, our Director of Primary Care is involved in the Newson Health Menopause Clinic 
and is exploring more widely through that resource any other national resources how we can 
use it to support the development of understanding and training.   

I hope that the above information has been helpful. Can I also take this opportunity to express 
my condolences to the family for their loss of Ms Moore. 

Please do not hesitate to contact me if you require further information. 

Your sincerely 

CHIEF EXECUTIVE 
Somerset NHS Foundation Trust