Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0297, written 13 Jun 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Jun 2025 |
|---|---|
| Reference | 2025-0297 |
| Deceased | Sally Burr |
| Coroner | Joseph Turner |
| Coroner area | West Sussex, Brighton and Hove |
| Category | Suicide (from 2015) |
| Organisation named | Sussex Partnership NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
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: The Chief Executive NHS England 1 CORONER I am Joseph TURNER, Area Coroner for the coroner area of West Sussex, 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 4 June 2024 I opened an investigation into the death of Sally Burr, aged 47. The investigation concluded at the end of the inquest on 11 June 2025. The conclusion of the inquest was that Sally Burr had died by suicide. 4 CIRCUMSTANCES OF THE DEATH Sally Burr had struggled with her mental health for much of her life. In January 2024 she was in crisis due to a number of stressors. Between January and April 2024 she attended the Emergency Department of local hospitals at least 3 times following overdoses or other attempts at serious self-harm. She was treated by a variety of the mental health services local to her in East Sussex, before being sectioned under s.3 MHA 1983 on 2 April 2024 and then admitted to Meadowfield Hospital in Worthing some days later. She had requested a transfer as she had worked as an Occupational Therapy Assistant in her local area and hence knew and feared that mental health staff there would know her, such that she felt unable to contemplate returning to work. Once at Meadowfield, she was allowed use of her mobile phone and access to the internet, in line with Sussex Partnership NHS Foundation Trust’s (SPFT – the Trust) policy. She was able to order legally available, but toxic, plant material (including and have them delivered to her home address. She also contacted a number of organisations and forums around ending her life. She extensively researched means and methods of ending her life. She did not inform or indicate to staff that she was doing so. ) online On return from limited leave on 12 May 24 she managed to bring some of the needles bought online back in to Meadowfield, hidden in her socks; despite personal and room searches these were not found. She then consumed these whilst detained on 30 May 24 with fatal results, despite emergency treatment. 5 CORONER’S CONCERNS During the course of 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: Regulation 28 – After Inquest Template Updated 23/05/2025 TG Whilst the Trust applied its policy on mobile phone use and internet access to Sally Burr correctly, it was clear that Sally was able to exploit this in order to research and obtain the means to end her life whilst a sectioned and detained patient. Staff at Meadowfield lacked any practical ability or means to know of, monitor or respond to Sally’s internet use. Whilst encouraged to express curiosity with patients as to their use of the internet, there were no technical means to control or monitor use, other than removal of devices or denial of internet access. However, this obviously risked a negative effect on Sally’s wellbeing and progress due to the wider impact of denying contact or information which would help and support her recovery (there was evidence that Sally was in contact with online support for her mental health). I heard evidence from the Trust as to revision of their policy and improved steps to try and prevent access to harmful or malign internet sites, but – rightly – such steps have to be balanced against the patient’s right to privacy, including communication. Those improved steps include blocking certain search terms and sites when using Trust wi-fi, identifying any attempted access by noting URLs, further restricting the time available for use, and heightening staff vigilance and awareness. However, the blocks can be easily circumvented by using 4G or 5G, and – as I know you will be aware – malign sites and searches often use euphemisms or seemingly innocent language and descriptions to avoid detection. I noted that the revised policy as regards patients under 18 includes only permitting phones which do not have internet access and/or that internet access is only available via public equipment which can obviously be monitored and checked after use. As such, my concern remains that permitting adult patients who have been detained under section access to the internet clearly provides an opportunity for them to be exposed to malign influences, and to obtain the means and methods to cause serious self-harm. I fully accept the difficulty and balance in recognising a patient’s right to a private life and how the least restrictive regime possible (including permitting communication) is intended to facilitate their recovery. I also and unreservedly accept the impossible task of policing the internet, but I identify that clearer and stricter rules, guidance and investment in technology (perhaps including AI) at a national level may be needed, to enable Trusts to be able to act consistently and uniformly in at least reducing the potential for patients to secure the means to end their lives whilst detained. 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 August 08, 2025. 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons (father) Sussex Partnership NHS Foundation Trust (brother) 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. Regulation 28 – After Inquest Template Updated 23/05/2025 TG 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: 13/06/2025 Joseph TURNER Area Coroner for West Sussex, Brighton and Hove Regulation 28 – After Inquest Template Updated 23/05/2025 TG
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.
Mr Joseph Turner
HM Area Coroner
West Sussex, Brighton and Hove Coroner Service
Record Office
Orchard Street
Chichester
PO19 1DD
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
30 July 2025
Dear Mr Turner,
Re: Regulation 28 Report to Prevent Future Deaths – Sally Burr who died on 30
May 2024.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 13
June 2025 concerning the death of Sally Burr on 30 May 2024. In advance of
responding to the specific concerns raised in your Report, I would like to express my
deep condolences to Sally’s family and loved ones. NHS England is keen to assure
the family and yourself that the concerns raised about Sally’s care have been listened
to and reflected upon.
Your Report raises the concern that allowing adult patients who have been detained
under section, access to the internet provides an opportunity for them to be exposed
to malign influences, and to obtain the means and methods to cause serious self-
harm. In the circumstances, you consider that clearer and stricter rules, guidance and
investment in technology may be required at a national level.
Your Report highlights the complexities of balancing a person’s right to a private life,
their continued connection with loved ones, enabling them to access information and
support online, and adopting a least restrictive approach to their care while maintaining
safety and minimising risk. NHS England’s Mental Health, Learning Disability and
Autism Inpatient (MHLDA) Quality Transformation Programme is working with
providers of inpatient mental health settings through the Culture of Care Programme
to support and improve understanding of a personalised approached to safety
planning. This includes prioritising the therapeutic relationship and connection
between staff and patients as a more reliable way of understanding a person’s risk of
harm to self and being able to collaboratively plan for ways to help keep people safe.
Whilst it is recognised that some inpatient mental health settings may have to
implement some blanket restrictions, we would always support a human rights based
and least restrictive approach to care that is based on individual needs.
We do, however, recognise that the use of technology within mental health settings is
a rapidly moving landscape and that staff need support to be able to make decisions
about how to implement new technologies safely and in a least restrictive way. We
recently published the Principles for using digital technologies in mental health
inpatient treatment and care in February 2025 which includes a number of key
principles as well as practical suggestions for providers.
My Patient Safety colleagues from NHS England’s South East region have engaged
with Sussex Partnership NHS Foundation Trust (SPFT) about the concerns raised in
your Report. The Trust has informed us that their internet use policy has been
amended to reflect this incident, strengthening the ability of frontline staff to take
organisationally supported decisions about restricting internet access / the use of
phones and laptops. We have been informed that the Trust has shared this policy with
yourself.
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 Sally,
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
NHS England
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