Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0153, written 19 Mar 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Mar 2025 |
|---|---|
| Reference | 2025-0153 |
| Deceased | Leanne Carroll |
| Coroner | Kate Robertson |
| Coroner area | North Wales (East and Central) |
| Category | Mental Health related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Kate Robertson Assistant Coroner for North Wales (East and Central) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Betsi Cadwaladr University Health Board (BCUHB) 1 CORONER I am Kate Robertson, Assistant Coroner for North Wales (East and Central) 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 2 July 2024 an investigation was commenced into the death of Leanne Marie Carroll (DOB 6/9/1996) who died on 29 June 2024. The investigation concluded at the end of the inquest on 17 March 2025. The conclusion of the inquest was a narrative conclusion that ‘Death was due to misadventure where Leanne had not been referred to the Perinatal Mental Health Service either during her pregnancy or at any point up to her death’. 4 CIRCUMSTANCES OF THE DEATH The circumstances of the death are as follows :- Leanne Marie Carroll was aged 27 at the time of her death on 29 June 2024. She had given birth to her first child approximately 8 months prior to her death. Leanne suffered from anxiety and, although not diagnosed, Obsessive Compulsive Disorder (OCD). She sought assistance from her GP and she was referred in March 2024 to the Community Mental Health Team. She was referred to an OCD support group. It was noted that her OCD had deteriorated since giving birth. Leanne died from the excessive consumption of prescribed and non-prescribed medications. At no time had any health professional referred Leanne to the Perinatal Mental Health Service who could have supported her. 5 CORONER’S CONCERNS During the course of the inquest, the evidence revealed matters giving rise to concern. Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 | In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows – 1. The Perinatal Mental Health Service was established across the Health Board around 5 years ago. It was accepted in evidence that there is insufficient awareness of the Service by health professionals including midwives, health visitors and GP’s. Whilst attempts have been made to raise awareness and encourage direct referrals to the Service (rather than via the Single Point of Access) this remains inadequate. If health professionals are unaware of the Service then mothers-to-be and mothers who require assistance will not be fully supported. 2. There are only 2 temporary perinatal health visitors across the 3 Health Board areas and not one in the Eastern area of the Health Board. By not having permanent perinatal health visitors acros all three Health Board areas then those who need to access support will suffer 3. The Single Point of Access meetings which occur on a daily basis by way of triaging referrals do not provide written records of the discussions had and decisions made. This means that there is no written justification for decisions made or written actions and therefore these discussions and decisions do not form part of any health record for the patient which would be relevant to the overall management of the patient. 4. I am concerned that deaths will occur into the future as awareness of the Service is not at all adequate to health professionals, the Service is not adequately staffed and records of meetings and decisions made in the Single Point of Access are not documented. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 14 May 2025. I, Kate Robertson, 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 Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 | I have sent a copy of my report to the Family of the Deceased and to the Chief Coroner. I am also under a duty to send the Chief Coroner a copy of your response. 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 19 March 2025 Signature Assistant Coroner for North Wales (East and Central) Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 |
1 response 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.
Bloc 5, Llys Carlton, Parc BusnesLlanelwy, Llanelwy, LL17 0JG ---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG Kate Robertson HM Assistant Coroner North Wales (East and Central) Coroner's Office County Hall Wynnstay Road Ruthin LL15 1YN Ein cyf / Our ref: Eichcyf / Your ref: : Gofynnwch am / Ask for: E-bost / Email: Dyddiad / Date: 13 May 2025 Dear Ms Robertson, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Leanne Marie Carroll I am writing in response to the Regulation 28 Report to Prevent Future Deaths dated 19th March 2025, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching the death of Ms Leanne Marie Carroll. I would like to begin with offering my deepest condolences to the family and friends of Ms Carroll. In the notice, you highlighted your concern that at no time had any health professional referred Ms Carroll to the Perinatal Mental Health Service. In response to the Notice, I requested our Mental Health and Learning Disabilities Division (MH&LD) consider your concerns and provide details of their plans to make our services as safe as possible, taking into account the learning from the inquest. Firstly, I would like to update you on the plans to raise awareness of the Perinatal Mental Health Service across the Health Board to ensure that mothers-to-be, and mothers who require assistance, are fully supported by the appropriate services. Currently, mandatory perinatal mental health training is delivered to midwifery colleagues, student health visitors, obstetricians and gynaecologists, Community Mental Health Teams (CMHT’s) and Home Treatment Teams (HTT). As extended members of the team, specialist perinatal health visitors provide training relating to the “Ask, Assess and Act Assessment Framework” whilst promoting the role of the Perinatal Mental Health Service. In addition, Institute of Health Visiting perinatal training is offered six times per year to the Health Visiting Teams, and members of the Mental Health Perinatal Team have undertaken train the trainer modules to disseminate this training further across the Health Board. Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: Swyddfa'r Gweithredwyr / Executives’ Office Ysbyty Gwynedd, Penrhosgarnedd Bangor, Gwynedd LL57 2PW Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk Moving forwards, the long-term plan is to integrate perinatal mental health training across the whole of the mental health acute care pathway to include in-patient services in addition to HTT, Psychiatric Liaison, and CMHTs. This is being processed through the Mental Health and Learning Disabilities Training and Development Group and it is expected that the perinatal awareness training will be fully ratified at the end of July 2025. Alongside this, the Health Board’s Perinatal Consultant Psychiatrist, , is leading on the development of training for GPs across North Wales. This training intends to increase knowledge of perinatal mental illness and the role and referral process for access to perinatal mental health assessment and support. is in the process of liaising with GP colleagues with the aim of having initial training dates agreed by the beginning of September 2025. With regard to Perinatal Health Visitors and the equity of access across North Wales, I can confirm that a review of Health Visiting Services across the Health Board that relate to wider perinatal services will be undertaken to determine whether gaps in service are evident. This will include consideration of access to specialist Perinatal Mental Health Services and the Mental Health Perinatal Service Manager will be involved within this process. An action plan will be developed to address any identified areas of need in order to ensure that there is equitable and appropriate access to perinatal services. Consideration will be given to the role and function of the Perinatal Health Visitor posts currently in place in the central and west areas on a temporary basis. This review will be undertaken with recommendations for the Health Board to consider by the end of July 2025. I would like to take this opportunity to provide you with an overview of how referrals to the Perinatal Mental Health Service are managed. These referrals are reviewed via the daily Perinatal Referrals Meeting. This meeting, like the Single Point of Access and Assessment meetings (SPOAAs) across the rest of the division, reviews each perinatal referral entering the system. The meeting is structured to meet the Royal College of Psychiatrist: Standards for Community Perinatal Mental Health Services (6th Edition). The requirement is that all referrals are reviewed within 24 hours of receipt and the screening discussion and outcome communicated to the referrer within a further 24 hours. There is a draft Standard Operating Procedure for perinatal services and this is progressing through Health Board governance process prior to final ratification and implementation. Within your notice, you raised your concern about the SPOAA meetings, in particular the records of meetings and the documentation of decisions made within the meeting. I would first like to provide you with an overview of the multi-disciplinary core membership of SPOAA meetings to demonstrate that the decisions are made by highly skilled and experienced clinicians. The core membership includes the Team Manager, Consultant Psychiatrist, Primary Care Practitioner, County Duty Practitioner and Older Persons Practitioner. In addition to those core members, attendance includes a Co-occurring Practitioner, Psychology, Therapies and Local Authority representation. There is dedicated administration for the meetings to ensure that the referrals are collated, and a Clinical System Review is undertaken to determine any previous contact with mental health services and to document the outcome of discussions and action required, that both the referral documentation and the SPOAA spreadsheet are updated. The updated referral document is filed within the patient’s records. For any downgraded referrals (urgent to routine), a communication or direct contact to the referring clinician/service is required to provide an opportunity for further discussion if required. These actions are underpinned by the Interim Standing Operating Procedure for the Delivery of the Mental Health Measure (Wales) function in the Community Mental Health Services for adults in North Wales. As an outcome of the inquest and subsequent notice, we have identified that consistency across the whole division is required in terms of the documentation used to record the summary and outcome of SPOAA Meetings. The Community Transformation Meeting taking place on the 21st May 2025 is reviewing the Interim Standing Operating Procedure mentioned above and specifically Appendix 1 (the “SPOAA Referral Checklist”) which is the agreed document that is filed within the patient records summarising the discussion at SPOAA and decisions/actions. The outcome of the meeting on the 21st May 2025 will be implementation of Appendix 1 across the division for all SPOAA Meetings from the 26th May 2025. The Community Transformation Meeting will review the existing Mental Health Measure audit that currently takes place, which includes SPOAA records, to ensure that the audit template and frequency is consistent across the division. With regard to staffing, I am able to confirm that the east Local Primary Mental Health Service is fully staffed and compliant with Part 1A and 1B of the Mental Health Measure. I hope this letter sets out for you the actions we have taken to ensure the concerns raised by yourself are being addressed and mitigated. We would be happy to meet with you and discuss our plans in more detail, or provide further information and assurance should that be helpful. Once again, I offer my deepest condolences to the family and friends of Ms Carroll for their loss. Yours sincerely Cyfarwyddwr Gweithredol Gweithwyr Proffesiynol Perthynol i Iechyd a Gwyddor Iechyd Executive Director of Allied Health Professionals and Health Science cc , Deputy Director for Legal Services
See every Prevention of Future Deaths report matching Mental Health related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.