Jacqueline Potter

Ms Samantha Marsh  
HM Senior Coroner  
Somerset Coroner’s Court  
Old Municipal Buildings  
Corportation Street  
Taunton  
Somerset  
TA1 4AQ 

Dear Ms Marsh, 

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

5 June 2025 

Re: Regulation 28 Report to Prevent Future Deaths – Jacqueline Anne Potter 
who died on 5 December 2022.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 24 April 
2025 concerning the death of Jacqueline Anne Potter (known as Anne) on 5 December 
2022. In advance of responding to the specific concerns raised in your Report, I would 
like to express my deep condolences to Anne’s family and loved ones. NHS England 
are keen to assure the family and the Coroner that the concerns raised about Anne’s 
care have been listened to and reflected upon.   

Your Report raises concerns around the importance of providing families with the tools 
and knowledge to assist in safeguarding loved ones with mental health illness when 
they  are  in  the  community,  along  with  the  perceived  lack  of  importance  given  to 
menopausal care available to women on the NHS. This response focuses on the issue 
of menopausal care and the areas which are within NHS England’s remit. 

Menopause and perimenopause are increasingly recognised as a time that can, but 
not always, cause considerable distress to a woman. We have seen a rapid increase 
in demand for menopause care in recent years, as a result of more media attention. 
Whilst  women  receive  high  quality  NHS  menopause  care  in  many  areas,  it  is  also 
acknowledged that variation across services locally / regionally remains.  

Many women who are experiencing menopause symptoms attend their GP for help 
and advice. Menopause care is part of the core curriculum for General Practice, which 
is the basis of training for all GPs in order to qualify. The GP curriculum: Clinical topic 
guides highlights menopause care as a requirement, which has more recently been 
updated to emphasise a changing landscape in the management of menopause, the 
need to be aware of the mental distress experienced by some women in this period, 
and being up to date on all evidence-based treatment options. Improving awareness 
of mental health symptoms during menopause will help GPs to consider this as one of 
the causes, and to provide appropriate advice and treatment options.  

Practice nurses also have a significant role in menopause care and are often the first 
port of call for someone experiencing difficulties, or who may have the opportunity to 
proactively enquire about the menopause. In 2024, NHS England published specific 

                                                                                                                       
 
 
 
 
 
 
  
 
 
 
 
 
  
 Menopause  Educational  resources  to  enhance  learning  for  practice  nurses.  As  the 
demand for menopause care has risen in recent years, some GPs and practice nurses 
seek  further  qualifications  in  more  specialist  care  such  as  the  training  programme 
offered by the British Menopause Society. Many GP practices will now have at least 
one member of staff who is able to offer more complex menopause care. Whilst this 
may  not  be  available  at  every  GP  practice  in  England,  in  many  practices,  and 
increasingly, there is a lead person who is able to offer this.  

There is often variation between GPs and practices in the level of complexity of care 
they are able to provide. Women’s Health Hubs were piloted in 2023/2024, seeking to 
reduce  the  variations  in  reproductive  healthcare  which  women  reported  receiving. 
They  provide  the  option  for  women  to  be  referred  to  more  specialist  reproductive 
health  care  (including  menopause  care)  if  the  GP  needs  further  advice.  Women’s 
Health Hubs have yet to achieve full coverage, but have the potential to fill the gap in 
care where this is more complex. NHS England is working closely with its regions and 
Integrated  Care  Boards  (ICBs)  to  ensure  that  every  woman  can  access  good 
menopause care wherever they are in the country.  

Working in a multidisciplinary team (MDT) alongside mental health practitioners, GPs 
and menopause specialists are an essential part of good menopause care and are a 
key element of a future neighbourhood model of care, which will help to ensure that a 
range of professionals are involved in the most complex cases.  

A toolkit that supports local areas to provide menopause information events and group 
consultations is under development to improve access and also to provide a forum for 
learning for other healthcare professionals. NHS England is working on menopause 
workforce support packages for employees and employers and developing a range of 
tools to upskill, including two e-learning packages (Menopause Awareness – elearning 
for  healthcare and  Menopause and people professionals  eLearning  for  healthcare), 
decision support tools and a self-care factsheet to empower women to understand and 
self-manage  their  perimenopause  and  menopause  symptoms,  and  to  point  them 
towards further sources of credible information.  

Whilst I acknowledge the Coroner’s comments regarding menopause resources and 
use of the NHS website, appreciating that online resources do not compare to patient 
consultations with a medically qualified professional, the menopause page on the NHS 
website  has  also  recently  been  updated  to  include  the  most  up-to-date,  evidence-
based information on menopause. This includes information about symptoms, where 
to seek treatment, lifestyle changes that may help with symptoms, and signposting to 
other helpful resources.  

NHS England’s StatMand Reform programme is leading work to optimise, rationalise 
and redesign statutory and mandatory training during 2025/26 in partnership with the 
Department  of  Health  and  Social  Care,  Health  Services  Safety  Investigations  Body 
(HSSIB) and NHS Resolution. There are three levels of mandatory training: 

1.  Nationally mandated – typically associated with statutory obligations, largely 
summarised  in  the  Core  Skills  Training  Framework  or  in  other  policy.  This 
includes training on subjects such as the General Data Protection Regulation 
(GDPR)  and  handling of  sharp  objects,  amongst  many  other things.  It  is this 

 
 
 
 
 
  
 nationally mandated training that NHS England is currently reforming (as stated 
above).  

2.  Locally mandated – each employing organisation will determine what should 
be mandated to all or most of their staff to meet priorities and patient needs. 
This training varies between organisations, with some similarities.  

3.  Profession or role specific mandated – this is determined by the respective 
professions and royal colleges and will form part of standards for professional 
development and curriculum for future trainees.  

The potential for menopause training to be mandated has been raised as part of the 
NHS  England  reform  work,  which  is  yet  to  conclude  it’s  work.  It  is  likely  that 
menopause training would most appropriately fit at a professional/role specific level 
and we expect to engage with profession leads and royal colleges in due course to 
consider this, alongside a number of similar topics, once the reform of the nationally 
mandated training has concluded.  

In addition, the Technology Enhanced Learning (Workforce, Education and Training 
directorate (WTE)) team at NHS England manage and host training on the e-lfh hub 
and  Learning  Hub  platforms.  National  WTE  colleagues  work  directly  with  subject 
matter experts within professional bodies and the NHS to design, develop and deliver 
e-learning training sessions/modules. They also work within defined medical training 
curriculums, as defined by the professional bodies and NHS England, and design and 
develop relevant e-learning sessions.  

Menopause  related  online  training  available  at  the  time  of  Anne’s  death  in  2022 
included training within the General Practice 2012 Curriculum (e-GP) programme. The 
e-GP  Programme  provides  a  programme of  e-learning modules  covering  the  Royal 
College  of  General  Practitioners  (RCGP)  curriculum.  The  programme  has  been 
designed to:  

1.  Facilitate the delivery of the RCGP curriculum at national, local and individual 

learner levels. 

2.  Provide  relevant,  comprehensive  and  accessible  learning  content  for  GPs 

working in the UK. 

3.  Embody adult learning principles and support a blended approach to learning.  
4.  Support postgraduate doctors in training to become GPs.  
5.  Support GPs in Continual Professional Development (CPD) and revalidation. 

The  e-learning  modules  which  are  part  of  this  programme  include  ‘What  is  the 
Menopause’,  ‘Managing  the  Menopause’,  ‘Hormone  Replacement  Therapy  (HRT)’ 
and ‘Premature Menopause’. 

Other menopause related online training includes:  

•  The  Sexual  and  Reproductive  Health  (E-SRH)  programme,  developed  in 
partnership with the Faculty of Sexual and Reproductive Healthcare (FSRH). 
The programme supports a range of healthcare professionals and compliments 
the redesigned FSRH Diploma (DFSRH) as well as other FSRH qualifications.  

 
 
 
 
 
  
 
 
 In recent years, the NHS England National Menopause programme has also launched 
a  series  of  awareness  sessions,  including  the  ‘Menopause  awareness’  and 
‘Menopause and people professionals’ e-learning packages referenced earlier on in 
this response, as well as e-learning on ‘Menopause and occupational health’. 

NHS England notes that some of the above training became available following Anne’s 
death,  but  hopes  that  this  provides  some  reassurance  to  the  Coroner  and  Anne’s 
family  that  additional  resources  have  since  been  made  available  to  healthcare 
practitioners and further improvements have been made to menopause care, training 
and resources.  

Anne’s tragic death has highlighted important gaps in the care of women experiencing 
perimenopause or menopause and the potential for improvements. NHS England will 
continue to promote high quality and equitable coverage of menopause care for all.  

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 Anne, 
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,  

Co-National Medical Director  
(Secondary Care)

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

10 June 2025 

Samantha Marsh  

Senior Coroner for the coroner area of Somerset 

Sent via email: 

Our reference: 

Dear Ms Marsh,    

Re: Regulation 28 Prevention of Future Deaths Report in respect of Jaqueline Anne 
Potter 

I write in response to your regulation 28 report, dated 24 April 2025, regarding the very sad 
death of Anne Potter. I would like to express my sincere condolences to Anne’s family.   

We would like to thank you for including NICE in this important report. We have reflected on 
the circumstances surrounding Anne’s death and the concerns raised. We note there are five 
distinct concerns raised in your report. It is important to note from the outset that we do not 
consider  the  concerns  raised  are  directly  attributable  to  NICE,  but  note  your  report  is  also 
addressed  to  NHS  England,  Somerset  NHS  Foundation  Trust,  the  Royal  College  of 
Obstetricians and Gynaecologists and the Royal College of General Practitioners. We have 
outlined the concerns below, detailing NICE’s response to each in turn.  

1.  The  lack  of  a  codified  ‘Risk’  and  ‘Safety  Planning’  document  to  be  given  to 
relatives  and  carers  to  assist  families  in  spotting  early  warning  signs  that 
‘something is wrong’ and to seek help and intervention (if/when appropriate) to 
minimise the risk of a patient taking their own life whilst in the community.  

We do not believe there is any NICE guidance that explicitly covers this matter, but our quality 
standard suicide prevention [QS189], quality statement 4, stresses the importance of asking 
the person if they would like their family, carers or friends to be involved in their care. The 
NICE  guideline,  self-harm:  assessment,  management  and  preventing  recurrence  [NG225] 
also has a number of recommendations that are not entirely specific to this situation, but that 
indicate  an  approach  of  involving  the  family  and  carers  (with  the  person’s  consent)  and 
providing written materials. For instance:  

1.10.1  ‘After  an  episode  of  self-harm,  discuss  and  agree  with  the  person,  and  their  family 
members and carers (as appropriate), the purpose, format and frequency of initial aftercare 
and which services will be involved in their care. Record this in the person's care plan and 
ensure  that  the  person  and  their  family  members  and  carers  have  a  copy  of  the  plan  and 
contact details for the team providing the aftercare’ (my emphasis). 

 
 
 
 
 
 
 
 
 1.5.15 ‘Together with the person who self-harms and their family and carers (if appropriate), 
develop or review a care plan using the key areas of needs and safety considerations identified 
in the psychosocial assessment’ 

1.4.1 ‘Be aware that even if the person has not consented to involving their family or carers in 
their care, family members or carers can still provide information about the person’. 

Our  guidance  emphasises  the  importance  of  involving  family  and  carers,  and  of  providing 
written information. We do not specifically mention the document or circumstances outlined in 
this report, but NICE’s recommendations are not intended to cover all clinical circumstances.   

2.  Wi-Fi access to harmful websites whilst in NHS facilities.  

NICE does not have responsibility for managing NHS care or services and therefore we would 
be unable to comment on this concern.  

3.  No compulsory training in menopause 

Again, we do not consider that this concern is directly for NICE as we are not responsible for 
setting the curriculum for undergraduate and trainee doctors in the UK, this is the role of the 
General Medical  Council (GMC).  We  understand  that there  is  currently  work  being  done to 
integrate menopause care into both GP and specialist training curricula, with menopause as 
part of the GP Specialty Training Curriculum (although still not a standalone module) and the 
RCOG  launching  a  Special  Interest  Training  Module  (SITM)  in  Menopause  Care  in  2024. 
However, only a very small number of trainees will access this. It is the view of our consultant 
clinical advisers that menopause care is not consistently or comprehensively taught across all 
UK medical schools, and there is no national standard requiring in-depth menopause training 
for all medical students. You may wish to share this part of the report with the General Medical 
Council (GMC)  and  with  Health  Education  England  (part  of  NHS  England)  for  their 
consideration. 

4.  Lack of menopause specialists or menopause services in the NHS  

We believe this concern will be better answered by NHS England and the Royal Colleges. 

5.  There  has  not  been  a  roll-out  of  specialist  menopausal  care  and  upskilling  of 

GPs, as was promised in a previous PFD.  

As noted above, we believe this concern will be better answered by NHS England and the 
Royal Colleges. 

We note your report also mentions a previous prevention of future death report sent to NICE, 
NHS England and Somerset NHS Foundation Trust in June 2024 on a similar matter. Within 
our  response,  sent  in  August  2024,  we  stated  that  following  publication  of  the  menopause 
update in November 2024, we would 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 the initial PFD. 

NICE’s surveillance team have informed us that ‘With the updates that have been made to 
menopause: identification and management [NG23] in November 2024 and the conclusions 
of the 2023 surveillance review, we are satisfied NG23 and the mental health guidelines are 

                                                                                                                                 Page | 2 

 
 
 
 up to date in relation to the HSIB report. We are tracking studies in this area identified by the 
2023 surveillance, so this topic will remain on surveillance’s radar’.  

I hope this response has helped outline our role and the recommendations that are in place 
on this important topic. I would like to reiterate my sincere condolences to Anne’s family.   

Yours sincerely, 

Chief Executive     

                                                                                                                                 Page | 3

Samantha Marsh 
His Majesty’s Coroner for Somerset 
Somerset Coroners Service       
Somerset Coroners Court                           
Old Municipal Buildings                              
Corporation Street                                    
Taunton TA1 4AQ                                       

Dear Ms Marsh, 

Re: Jacqueline Anne Potter 

19 June 2025 

Thank you for your Regulation 28 Report to Prevent Future deaths following the inquest into 
the death of Jacqueline Anne Potter on 24 April 2025. 

This loss is a devastating tragedy for the immediate and the wider family, and the 
healthcare professionals involved. We would like to begin by extending our deepest and 
heartfelt condolences to Anne’s family for their profound loss. 

This response has been developed following input from members of the Royal College of 
Obstetricians and Gynaecologists (RCOG) Patient Safety Committee and Senior Officers of 
the College.  

We recognise and respect the narrative conclusion from the inquest that Anne died from 
multiple traumatic injuries through suicide, secondary to her menopausal symptoms 
contributing to her mental health decline and exacerbation of her underlying anxiety. 

We also recognise the matters of concern as outlined in your letter as follows,  
‘Certain elements of medicine and clinical practice training are compulsory but having heard 
evidence at the Inquest around mandatory and statutory training modules I learnt that this 
covers areas such as GDPR training and disposal of sharp objects such as syringes. I was 
surprised to learn that menopausal training is not mandatory in any area of clinical practice 
or specialism. I am concerned that there is no requirement to undertake essential 
compulsory menopausal training for those working in ‘relevant’ clinical practices such as 
Mental Health Practice, Obstetrics and Gynaecology and Oncology, or even general as a 
general GP’. 

Page 1 of 2 

 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 At present, it is only a requirement for doctors on the General Medical Council’s specialist 
register for obstetrics and gynaecology to have demonstrated competency in menopausal 
and postmenopausal care. 

To support doctors in this aim, the RCOG provides educational initiatives, including its 
curricula on which the MRCOG qualification is based and tested through examinations, 
elevating care standards through clinical guidance, assisting in career advancement through 
examinations, coordinating professional development initiatives and events, and offering 
support services to its members.  

The RCOG’s core training curriculum which provides a framework for the training of 
Obstetricians and Gynaecologists ensures that management of the menopause is covered as 
a key skill. Understanding and management of the menopause is a key area on the syllabus 
for the MRCOG examination, which is an essential qualification in our speciality.    

The College also has a Special Interest Training Module (SITM) in menopause care. This SITM 
is aimed at learners with an interest in menopause care. It provides training on how to 
assess and investigate women with menopause-related symptoms, understand the benefits 
and risks of HRT and alternative therapies, and counsel and advise women accordingly.  

Additionally, for General Practitioners who would like to develop a more advanced 
knowledge of women’s healthcare, the RCOG also provides the Diploma of the Royal College 
of Obstetricians and Gynaecologists (DRCOG). The core syllabus for this examination also 
includes diagnosis, investigation and management of the menopause. The DRCOG is 
primarily undertaken by those in General Practice who have an interest in Women’s Health 
but is not mandatory. 

Throughout the course of each year the RCOG and our Specialist Society (British Menopause 
Society) also host numerous training and education events which are accessible to all 
healthcare professionals, several of which support additional education into various aspects 
of care for menopausal women. 

I hope this is a helpful response to this matter.  

Yours sincerely, 

Chief Executive 
Royal College of Obstetricians and Gynaecologists 

Page 2 of 2

30 June 2025 

Mrs S Marsh 
c/o Somerset Coroner’s Court 

Sent via email to  

Dear Mrs Marsh 

Trust Management Headquarters
Trust Management Headquarters 
Yeovil District Hospital
Yeovil District Hospital
Higher Kingston
Level 1 
Yeovil
BA21 4AT
Peter.Lewis@somersetft.nhs.uk

REGULATION 28 REPORT – PREVENTION OF FUTURE DEATHS – Jacqueline Anne 
Potter  

I am writing in response to your correspondence dated 24 April 2025 regarding the Regulation 
28 Notice of the Coroner’s (investigations) Regulations 2013 following the inquest regarding the 
death of Jacqueline Anne Potter which concluded on 7 March 2025.  

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

MATTERS OF CONCERN 

Part One 
1. 

Lack of Risk and Safety Planning document for section 17 (MHA) leave 

Following the concerns raised by the family and the coroner in Mrs Potter’s inquest, the 
Mental Health and Learning Disability Service group have developed supportive 
guidance for families and people who matter when a patient is on Section 17 Leave from 
an inpatient unit. This is currently out for feedback from teams and will be shared at the 
operational meeting next month for approval prior to production via the patient 
information team.  We will also be sharing the draft document with service users and 
carers to ensure it covers the information that they feel is necessary to support them. 

We believe that this document will provide additional support and information for families 
and people who matter to give them the knowledge to assist them with understanding 
the purpose of leave, their role and contact details should they require advice and 
guidance or emergency support.  

The document sets out why Section 17 Leave is beneficial to patients, how and by 
whom it is granted, an explanation of risk assessments that are carried out ahead of 
leave, and what the role of the family member or carer is during that time.  

The role of the family/carers is described as providing a safe and calm environment 
during the period of leave, encouragement of routines such as regular meals and 
medication, to act as a point of communication with any concerns to hospital staff and to 
assist the patient to return on time as agreed. There is also the option for the relative or 
carer to discuss any concerns with this level of responsibility, and to not accept it if they 
feel unsure or unable. There is also key information if they have concerns of who to 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 contact, what numbers to use and what concerns they may want to call the inpatient 
ward about if they are unsure.  

The guidance stresses there is support available 24 hours a day, even if it is just to seek 
some guidance and who to contact in a more urgent situation.  

2. 

Wi-Fi access whilst in an inpatient mental health unit 

Following the inquest, further enquiries were made on this point within the Trust with our 
cyber security manager.  

All Trust devices accessible to patients on our inpatient mental health units have 
parental control software installed which filters out inappropriate content and restricts 
access to harmful material. This is in addition to security features on our Wi-Fi which 
blocks certain categories from view as part of our web filtering policy. This is a Trust 
wide approach. 

Additionally, some desktop devices in some inpatient mental health sites have a browser 
extension loaded onto the device which will divert users away from certain search terms 
to a free, 24/7 mental health support site. This can only be used on PCs and is not 
suitable for mobile devices, but it effectively blocks patients accessing this type of 
information when they use a search engine on a ward PC e.g. google, safari. Our IT 
team explained that they could not currently see that this programme is available to 
download onto mobile devices.  

Private devices would not connect to the Trust Network, due to security reasons, and 
instead would connect to the public ‘NHS Wi-Fi’ which is essentially a connection 
straight out to the internet.  Any changes made to this connection would have to be 
made county-wide and would affect all devices which connect to it.   

The Trust has a Standard Operating Procedure for our mental health wards which 
outlines the parameters for use of Trust and personal IT equipment on the wards and 
includes guidance on when access to mobile phones and the internet may be restricted 
or withdrawn.  The guidance lists considerations of risk related to the use of mobile 
phones, including if the patient has a history of accessing self-harm or suicide related 
websites.  

Part 2 

3. 

Menopause and Mental Health 

We have previously responded about the changes that have occurred at Somerset NHS 
FT over the last 2 years in relation to education and training around the link between 
mental health and menopause. 

There is an ongoing task and finish group which is leading on this piece of work and has 
focused on improving clinicians understanding of what to look for, ask about and 
consider when assessing patient who may fit in this category. If there is a potential 
consideration, we add a prompt to our electronic patient record, Dialog+, to ask these 
questions. Whilst it is not expected that mental health clinicians will make a primary 
diagnosis of menopause we expect it to be on the list of considerations of patients who 
meet the criteria. For the clinician there must be consideration of what Mental Health 
and menopausal symptoms might look like, with an awareness of potential for 
overshadowing, and the 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. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We also recognise the importance of, and support colleagues to undertake, screening 
and signposting patients to other services and websites which offer support and 
guidance for those who may meet the criteria for menopause to be considered..  This 
includes the updated NICE guidance, Overview | Menopause: identification and 
management | Guidance | NICE. The 2024 update includes the consideration of 
psychological support for early menopause and cognitive behavioural therapy as a 
possible management option. There is also additional guidance on the use of HRT for 
the management of depressive symptoms, which do not meet the criteria for a diagnosis 
of depression, associated with menopause within the guidance which can provide a first 
line approach for GP’s managing patients and for mental health professionals to 
highlight in communication with the patient’s GP if they feel the patient meets this 
criteria.  

We still have the benefit of having the Director of General Practice working at the Trust 
who is a specialist in menopause management. This is not something many secondary 
care providers have. Dr Patrick supports the mental health team and the wider trust in 
providing up to date education and support, which involves training sessions of what to 
look for and consider, and where to signpost. There are further dates for training for 
colleagues being arranged.  

I hope that the above information has been helpful. Can I also take this opportunity to express, 
personally and on behalf of the Trust, my condolences to the family of Mrs Potter, for their loss. 

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

Yours sincerely 

Chief Executive 
Somerset NHS Foundation Trust