Samantha Young

Parliamentary Under Secretary of State 
for   Women’s Health and Mental 
Health  

39 Victoria Street  
London  
SW1H 0EU  

HM Assistant Coroner Henry Charles  
Coroner’s Office,  
Castle Hill,  
Winchester,  
Hampshire, 
SO23 8UL  

                                                                                                            16 October 2025  

Dear Mr Charles  

Thank you for your Regulation 28 report to prevent future deaths dated 25 July 2025 
about  the  death  of  Samantha  Kate  Young.  I  am  replying  as  the  Minister  with 
responsibility for mental health.   

Firstly,  I  would  like  to  say  how  saddened  I  was  to  read  of  the  circumstances  of 
Samantha’s death, and I offer my sincere condolences to her family and loved ones. 
The circumstances your report describes are concerning and I am grateful to you for 
bringing these matters to my attention.   

I have noted the contents of your report, and the matters of concern raised relating to 
the  local  provision  of  risk  assessment  training  for  agency  staff  and  guidelines  and 
procedures  around  communications  with  family  and  friends  of  patients  with  mental 
health difficulties. In responding, I have liaised with NHS England and Hampshire and 
Isle of Wight Healthcare NHS Foundation Trust.     

I  have  been  informed  by  the  Trust  that  the  position  in  respect  of  agency  staff  and 
training  is  a  complex  one  as  agency  nurses  are  employed  by  their  agencies  and 
typically do not have access to the in-house training programmes of the NHS Trusts 
they  work  at,  for  a  number  of  logistical  and  financial  reasons.    However,  given  the 
specific focus on risk management arising from this case and more generally, the Trust 
is considering ways in which it can better support agency staff to develop in this area.   

In recognition of the importance of engagement with families and carers, the Trust last 
year commissioned an independent audit of this area. Specifically, the purpose of the 
audit  was  to  review  the  adequacy  of  the  Trust’s  arrangements  for  involving  and 
listening  to  families  and  carers  so  that  the  Trust  learns  from  their  feedback  and 
experiences. The findings of the audit underline the Trust’s commitment to ensuring 

  
  
  
  
   
 
 
  
  
  
  
  
  
 that  patients’  families  feel  heard,  respected,  and  involved  in  the  care  of  their  loved 
ones. The findings also outline the programmes of work that are in place as the Trust  

seeks to embed a culture of compassionate, inclusive care across all of its services, 
which  include  improved  collaboration  with  partners  and  other  organisations; 
improvements to its Triangle of Care initiative; and upskilling staff coaches supporting 
the  development  of  colleagues  to  create  a  culture  of  continuous  improvement  and 
ensure person-centred care.   

I  understand  that  more  detailed  information  about  these  issues,  along  with  the  key 
findings  of  the  Trust’s  independent  audit,  has  been  provided  by  the  Trust  in  its 
response to your report.   

I hope this response is helpful. Thank you for bringing these concerns to my 
attention.   

Yours sincerely,

17 September 2025 

HM Assistant Coroner Henry Charles 
Hampshire, Portsmouth and Southampton Coroners Service  
Castle Hill 
The Castle  
Winchester  
SO23 8UL 

Trust Headquarters
 7 Sterne Road 
Tatchbury Mount
Calmore
Southampton
SO40 2RZ

Dear Mr Charles 

Please find enclosed the Trust’s response to the Regulation 28 report issued following the  
inquest into the death of Samantha Young. There has been considerable discussion of the issues you 
raised and the response has had input from a number of executive directors as well as senior clinical 
staff. 

I trust our response helps you understand the steps we are taking to address these areas and that you 
will not hesitate to contact me should you have any further queries. 

Yours sincerely 

Chief Finance Officer, Deputy Chief Executive and SIRO 

Enc. 

Hampshire and Isle of Wight Healthcare NHS Foundation Trust Headquarters,  
Sterne 7, Tatchbury Mount, Calmore, SO40 2RZ 
Telephone: 023 8231 0000 | Website: www.hiowhealthcare.nhs.uk 

 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 A. Assessment of the risk that a patient poses to themselves or others is clearly a cornerstone of the work of 
an NHS Trust dealing with mental health. At the material time there was a lack of any training as to compilation 
of risk assessments. I was informed by a senior manager of Hampshire and Isle of Wight Healthcare NHS Trust 
that with the translation of Southern Health NHS Foundation Trust into the new Hampshire and Isle of Wight 
Healthcare NHS Foundation Trust that issue of training is being addressed. However it emerged at the inquest 
that there do not appear to be any firm plans to train agency staff. Agency staff form a significant percentage 
of frontline staff. Hampshire and Isle of Wight Healthcare NHS Trust should review its provision of training for 
agency staff, in particular in respect of risk assessments.  

Ensuring we have a workforce that is both competent and confident in carrying out key activities to 
provide safe care to the patients we support is a high priority for us as an organisation. As such we 
have recently reviewed our training offer to ensure that staff are allocated role specific core training 
alongside their mandatory training requirements.  

As was described in evidence at the inquest, a programme of risk management training is being 
developed for staff working in mental health services in order that this is standardised across our 
relatively new organisation. The finer details of the programme and practical elements such as mode 
and duration of delivery are being worked through, and the intention is to roll the programme out 
across the organisation in 2026.  

By way of some context, it is important to note that risk management, for a mental health registrant, 
will have been an integral part of core training. Student nurses’ skills in risk assessment will be 
assessed within every student placement undertaken and form a core competency that must be met 
and signed off prior to successful completion of nurse training. In that respect, the risk training we will 
be providing to our staff is intended to be a refresher which allows for the most recent best practice to 
be reflected upon, thereby maintaining confidence in practice.  

The position in respect of agency staff and training is a complex one. On the one hand, agency nurses 
are not our employees and often are a very transient part of the workforce. They are employed via 
their agencies and typically do not have access to the in-house training programmes of the various 
NHS Trusts they work at for a number of logistical and financial reasons.  

By virtue of choosing to work via an agency, their access to training will typically not be through a 
single training department as would primarily be the case for staff employed by the NHS. Instead, 
whilst many agencies will provide access to statutory and mandatory training, it is the responsibility of 
the agency nurses to maintain their continuing professional development beyond this by accessing 
any additional training they may deem necessary. This can be from a multitude of different routes 
including accessing private training providers, freely available e-learning programmes or through 
professional journals, attending conferences/workshops etc.  This onus on registrants to take 
responsibility for remaining competent in their area of practice is clearly set out in the Nursing and 
Midwifery Council’s Code of Conduct.  

It is unfortunately not feasible for an NHS Trust - already incurring significantly higher costs for agency 
staff - to also absorb the additional expense of providing them all with access to the full training 
programme offered to its own employees, particularly when there is no guarantee that the agency 
member will return to the Trust after their initial placement. 

All that being the case, we of course recognise that we have a duty of care to ensure that our patients 
are being seen by staff who are qualified and competent to do so, whatever their contractual position 
in so far as employment goes. Whilst this duty of care is in part discharged through the frameworks 

 
 
 
 
 which govern the agencies in question (which require them to ensure their staff are appropriately 
trained) we are keen to explore what more we can do.  

Given the specific focus on risk management arising from this case and more generally, we are 
considering ways in which we can support agency staff to develop in this area. 

The particular group of agency staff we are keen to prioritise are those staff working in the community 
where they are likely to be on longer term placements. By the nature of their work in community 
teams, they will hold a more central role in the risk assessment, formulation and management of a 
patient.  

Pending the roll out of our new risk management training programme for our staff, community mental 
health teams are now receiving bespoke risk management training sessions delivered on a team-by-
team basis at their local base. These sessions are open to both agency and substantive staff.  

Work is also underway to agree what training material can be shared with the agencies we contract 
with in order for them to signpost this to staff who are due to be starting on our longer-term 
placements. By way of an example, at the end of August 2025, NHS England released an e-learning 
programme called Staying Safe from Suicide. It is accessible for all staff including those working in the 
private or voluntary sectors.  We intend to make this one of the training modules that the agencies we 
work with will need to signpost staff to prior to them accepting a community placement with us. 

In planning the delivery of our new risk management training programme we will also consider what 
other ‘pre-course’ material it would be useful for staff to have reviewed. Any additional material 
identified will be passed to agencies in the same way as above. 

When we roll out the new risk management training programme we will also ensure it is available for 
long-term community agency staff to attend in the same way that it is for our substantive staff. 

A new induction checklist has also been introduced that substantive staff go through with agency staff 
when they commence a placement. Following receipt of your report, this is being revised to include a 
specific prompt and self-declaration around risk management competency. 

We believe the above steps will help encourage agency nurses to focus on risk management as one 
of the key areas for their ongoing professional development where they are working in roles that see 
them at the centre of risk assessment, formulation and management. As with our substantive staff, 
access to supervision and the wider multidisciplinary processes in place are additional key 
components in supporting these agency staff with the management of risk.  

Whilst the above steps will ensure our long-term community agency staff are on a similar footing to 
Trust employees in respect of risk management training, the situation is admittedly more complex with 
our more transient agency workforce. These are staff who might have as little contact as attending a 
ward for a single shift with very short notice and who do not then work for the Trust again for several 
months. This staff group do not undertake the type of risk formulation and management that our 
longer-term community agency nurses do. We will be asking the agencies we work with to specifically 
ensure that these staff have maintained their competence in risk management but need to be upfront 
about the fact that logistically the other measures described above are not possible to take with this 
group.  

Ultimately, we are seeking to reduce our reliance on agency staff to ensure a more consistent 
workforce. There has been a huge amount of work undertaken already and we have seen significant 
reductions as a result, with our agency use reducing by 65% between September 2023 and August 
2025.  

 
 B. Wider family and friends of the deceased perspective were not contacted. A patient's family and friends are 
clearly an invaluable resource for learning more about a patient's mental health and specifically risk to life, the 
support available to the patient and the potential for synergistic support with the NHS Trust. This PFD is not 
the first time that the issue has been raised with Southern Health NHS Foundation Trust: in 2023 the Senior 
Coroner for Hampshire, Portsmouth and Southampton issued a PFD on similar grounds arising out of the inquest 
into the death of Kirsty Taylor. The Senior Coroner observed in the PFD that "I remain concerned (as it is a 
matter I have raised on many occasions at inquest and again as a result of the experiences of the family in 
this case), that communication with the families of patients with mental health difficulties is still not being 
effectively  achieved.  Nor  are  such  families  being  sufficiently,  effectively  and  meaningfully  listened  to  or 
understood  when  they  voice  concerns,  based  on  their  experience  of  the  patient  outside  of  a  treatment  or 
assessment environment. Consequently, I am concerned that such matters are not being reflected sufficiently 
or  frequently enough  in the  onward treatment of those  patients or  in  the  clinical curiosity  afforded to their 
conditions." Moreover, in 2021 a report commissioned by NHS England into Southern Health Foundation Trust 
similarly reported on shortfall in communication with families. 
Hampshire  and  Isle  of  Wight  Healthcare  NHS  Trust  should  review  guidelines  and  procedures  concerning 
communication with family and friends of patients with mental health difficulties by its permanent and agency 
staff, and monitoring of whether such communication has taken place. 

We are saddened by the concerns raised by Samantha’s family regarding their experience of care, 
and we extend our sincere condolences for their loss. We recognise the importance of listening to 
families and learning from their lived experiences, especially when they feel let down by the care 
provided. 

The Trust takes the findings of this Regulation 28 report seriously. We also acknowledge the reference 
to previous reports, including an earlier Regulation 28 and the wider NHS England report from 2021. 
This latter report was instrumental in shaping a significant programme of improvement across the 
organisation, particularly in how we engage with families and carers. 

While we accept that Samantha’s family's experience highlights areas where further progress is 
needed, it is not reflective of the Trust’s overall approach or the substantial work undertaken to 
improve carer engagement. The Trust serves a large and diverse population - we have a team of over 
13,000 staff, who provide services across 500 different sites, in people’s homes, GP surgeries, care 
homes, community hospitals and general hospitals. Despite our best efforts, and the ability to 
evidence significant programmes of work seeking to improve carer engagement, there will be 
occasions where individual experiences fall short of our expected standards. These instances are 
deeply regrettable and are treated as opportunities for reflection and learning. 

We are committed to ensuring that every family feels heard, respected, and involved in the care of 
their loved ones. In the sections that follow, we outline the programmes of work that are in place as we 
seek to embed a culture of compassionate, inclusive care across all services. We also share the key 
findings from our internal auditors which confirmed that we have robust guidelines and procedures in 
place in this regard. 

Collaboration with Partners and other Organisations 

We work collaboratively and in partnership with a number of carer organisations and partners.  A 
number of these carers organisations and carers and families have been engaged in the process to 
develop a new strategy for our newly formed organisation which was launched in June 2025. 

The Trust works in collaboration with Hampshire Carers Together who are responsible for delivering 
the Joint Carers strategy for Hampshire.  We are a member of the action group, and this enables us to 
ensure that our work is aligned.  The Portsmouth Carers centre also published their carers strategy 
and they are now members of our Carers, Families and Friends group.   

Triangle of Care 

The Triangle of Care is an initiative promoted by the NHS, developed by the Carers Trust, to foster a 
therapeutic alliance between the service user, their family or carers, and the professional staff involved 
in their care. It emphasizes partnership, communication, and shared responsibility to promote safety, 

 
 
 support recovery, and sustain the wellbeing of both the service user and their carer. Having rolled out 
the programme to legacy Southern Health staff over a number of years, we are now introducing the 
Triangle of Care framework to our staff in Isle of Wight and legacy Solent teams (who merged with 
Southern Health last year to become Hampshire and Isle of Wight Healthcare). Much of this training is 
co-delivered with carers, carers leads and a former service user with their carer.  The training has 
recently been updated in coproduction with carers. 

The aims of ‘triangle of care’ are clear:  

  Carers and the essential role they play should be identified at first contact or as soon as 

possible thereafter 

 

 Staff are “carer aware” and trained in carer engagement strategies  

  Policy and practice protocols re confidentiality and sharing information are in place  

  Defined post(s) responsible for carers are in place  

  A carer introduction to the service and staff is available, with a relevant range of information 

across the care pathway. E.g. Trust Carers Booklet.  

  A range of carer support services is available.  

The introduction of Esther coaching has further enhanced and reinforced the Triangle of Care 
principles. Esther Improvement Coaches are specially trained dedicated members of staff who support 
the development of other staff to create a culture of continuous improvement to ensure person-centred 
care. User involvement is integral to the model, building a network around the patient including family, 
friends, and key staff.  

Currently we have in excess of 90 staff members as ambassadors. This training is unique to us as we 
decided that we needed a way of sharing and promoting ESTHER by involving more staff in the 
project. Having ESTHER ambassadors helps us to share the ESTHER message far and wide and 
gives us a strong network across the organisation. The ambassadors form a key part of our Trust-wide 
ESTHER network, which meets on a quarterly basis to share best practice, learning, and updates 
about ESTHER. They also get updates via email which they can share with their teams/ divisions and 
networks. In addition, we offer Esther coaching courses. 

The aim of the coaching course is to upskill staff in soft skills such as coaching skills/ managing 
conflict/ storytelling and how to facilitate this, as a few examples. We look at topics such as consent to 
share, person-led care planning, and collaborative working. We also spend time exploring how we can 
make stories more central to our work and run sessions or ESTHER cafés where people can share 
their story with the team. 

As an example, one of our coaches is from our Early Intervention in Psychosis (EIP) team and they 
have since used ESTHER and its principles to launch a project focused on how they work with carers 
and families. This started as an ESTHER café, and the feedback and stories shared at this have then 
helped develop their quality improvement project and carers continue to be involved. They meet 
monthly and have had positive feedback from those involved: 

 

 

“It feels a real listening, sharing & collaborative space.  I can also see this sharing actually 
translating into real & tangible outcomes.” – a carer. 

“The meetings are very inclusive and my views are listened to and openly received. It is very 
positive that EIP is actively seeking change in Mental Health services.” – a carer. 

Carers Champions (Carers Leads) 

To support our focused work with carers and families there are Carers Champions in each team, and 
additional Carers Champions considered as “honorary” Carers Champions across the Trust. There 

 
 were 165 Carers Champions at the end of the 24/25 financial year and 56 Honorary Carers 
Champions. (Honorary Carers Champions are the ambassadors and influencers for all things carer-
related). 

Carers communication/information plans 

Our new Carer Information Plan officially launched in May 2025, and is available for all services, 
replacing the previous Carer Communication Plan. Carers were involved in the development of our 
new plans and the response has been overwhelmingly positive. 

This isn’t just a system update but instead is a meaningful shift in how we recognise, value, and 
support carers across our Trust. Now live in our electronic patient record, RiO, the Carer Information 
Plan helps staff easily record key details about the carers involved in a service user’s life, making sure 
their voices are heard and their contributions are acknowledged. 

What makes this plan special is its focus on what really matters. It goes beyond basic information to 
include communication preferences, the kind of support carers provide, and personal insights like 
routines, hobbies, and known triggers of the service user. These details help us deliver care that is 
truly person and family-centred, strengthening the partnership between carers and care teams. 

We have also built this plan with privacy and protection in mind. It includes clear consent protocols 
and separates information appropriately, ensuring we meet GDPR requirements while staying true to 
the principles of the Triangle of Care. 

Feedback has been really positive - staff have told us the plan makes it easier to connect with carers 
and tailor support. Carers have shared how valued and included they feel with many saying it is the 
first time their role has been properly recognised in this way. 

Information Sharing  

Policies and protocols with regards to information sharing (including the issue of capacity) are also in 
place. The Trust promotes the importance of both the 7th and 8th principles of the UK Caldicott 
Guardian Council in recognising the importance of the duty to share information being as important as 
the duty to protect patient confidentiality. They are included with our Triangle of Care work and 
information governance (IG) training. IG training is completed annually by every member of staff which 
will help to embed these principles further. 

Information sharing remains a real focus of ours and we take every opportunity to champion this work.  
Our Carers booklet, which was co-produced with carers and is handed out to family/carers whenever 
they come in to contact with services also has specific references to information sharing.  

Obtaining and providing feedback 

The Trust has increased the number of ways that people can give feedback and opportunities to share 
their experience. This includes Carers groups, storytelling events, carers forums, surveys etc. We 
have a number of carers groups across the Trust, as well as supporting external groups. Most 
recently, the Trust has funded and supported the setting up of a BAME carers group in Southampton 
and continue to fund an adult mental health carers group from diverse communities.  Feedback and 
issues highlighted from these different platforms is reported to the services involved, the Carers, 
Family and Friends group and the Patient Experience and Caring group as part of our business-as-
usual reporting.  As we develop our new Trust, an overarching Experience of Care group will be 
established and an unpaid carers group will report into the Experience of Care group. 

Independent assessment of Trust performance in this area 

In December 2023, representatives of the Hampshire and Isle of Wight Integrated Care Board (HIOW 
ICB) and NHS England (Southeast) reviewed evidence provided by the Trust to demonstrate 
sustained improvement against a number of actions that had arisen from the 2021 NHS England 

 
 
 report referenced in this Prevention of Future Deaths report. They found that there had been 
considerable efforts made by the Trust and its staff to demonstrate improvement across the following 
key areas:  

  Complaints handling  

  Communication and liaison with patients’ families 

 

Investigative structure and process to conduct transparent and fair investigation into serious 
accidents, deaths and complaints  

  The extent to which recommendations from previous investigations have been developed, 

implemented and monitored. 

In continuing recognition of the importance of carer engagement, the Trust last year commissioned an 
independent audit of this area. Specifically, the purpose of the audit was to review the adequacy of the 
Trust’s arrangements for involving and listening to carers in order that the Trust learns from their 
feedback and experiences. This was undertaken by our Internal Auditors—an external professional 
organisation specialising in governance and assurance. Their involvement reflects the seriousness 
with which the Trust approaches this issue. 

Received in January 2025, the independent audit report found ‘there are comprehensive guidance and 
robust processes developed to ensure the national Carers Strategy and Triangle of Care guidance are 
followed across the Trust. A Carers Plan is in place to track ongoing actions and initiatives related to 
supporting carers. Triangle of Care standards are well communicated to all staff through training and 
engagement events. A robust governance structure has been established (prior to merger) to ensure 
effective oversight on the Carers Plan and carers’ feedback, which is collected through various 
channels, including surveys, engagement events, and meetings. On this basis it found the control 
design to be ‘Substantial’. 

The audit report goes on to find: ‘The control effectiveness is Moderate as the Trust has been 
monitoring the Carers Plan and improvement initiatives properly with sufficient evidence available to 
prove their delivery progress. However, while the Trust uses OpenRio to record patient and carer 
information, it does not currently capture all essential data, which could limit its ability to monitor carers 
identification and support provided. Moreover, new roles and responsibilities of the Carers team are 
still being defined post-merger.  

The data issue has been remedied with the information now captured on our data insights 
visualisation platform. Furthermore, the Trust is now nearly 1 year post merger, resulting in greater 
alignment in the Carers function across the new organisation with further work ongoing in this regard. 

Agency staff 

The Trust recognises that high-quality carer engagement must be embedded across all teams, 
including those supported by long-term agency staff. To this end, both the Triangle of Care training 
and the Esther coaching is delivered in a number of different formats to maximise access and this 
includes it being available to agency colleagues working in community placements. 

In addition to formal training, agency staff are immersed in the culture and practices of the teams they 
work within. These teams will promote carer involvement through the work of carers champions and 
agency colleagues are expected to uphold the same standards. Furthermore, all staff, including 
agency workers, are required to complete the Carers Information Plan described above as part of their 
record keeping, which ensures that carers are identified, informed, and supported throughout the care 
journey. This approach helps ensure that carer engagement is not dependent on employment status 
but is a shared responsibility across the entire workforce.