Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0520, written 11 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Oct 2025 |
|---|---|
| Reference | 2025-0520 |
| Deceased | Sarah Healey |
| Coroner | Joseph Turner |
| Coroner area | West Sussex, Brighton and Hove |
| Category | Other related deaths |
| 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: MP Secretary of State for Health and Social Care 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 8th August 2024 I commenced an investigation into the death of Sarah Louise Healey aged 32. The investigation concluded at the end of the inquest on 10 October 2025. The conclusion of the inquest was that: On 4th May 2024 Sarah Healey was admitted to Worthing General Hospital with severe malnutrition and complex infections. She remained in hospital and was treated for various serious conditions, including a period under Mental Health Act detention, which was discontinued on 30 July 2024. She underwent procedures but, despite active treatment, she deteriorated on 1 August 2024, became extremely hypoxic and sadly died the same day of respiratory failure, secondary to pleural effusions, caused by hypalbuminaemia and malnutrition, contributed to by a lack of physiological reserve. Her complex medical issues arose from Avoidant Restrictive Food Intake Disorder, arising in turn from longstanding mental health issues including Generalised Anxiety, Post Traumatic Stress Disorder and agoraphobia. These were due to a series of abusive and violent incidents in her teens, and other stresses. These had recently resurfaced, exacerbating her mental and related physical conditions. It was admitted that Sarah had not received appropriate, consistent mental health care between January 2022 and March 2024 and that this more than minimally contributed to her death. 4 CIRCUMSTANCES OF THE DEATH Prior to her admission to hospital in May 2024, Sarah had lived a reclusive life, confining herself to her bedroom at her parent’s house, since around the age of 20. Although not formally diagnosed at the time, in addition to the conditions listed above, Sarah had shown behaviours strongly suggesting autism since childhood. For the last 12 years Sarah had followed an extremely limited diet, leading to increasing malnutrition. Her GP had referred her multiple times over the years to Mental Health Services. There was an extensive history, given Sarah’s physical and mental conditions, with the Regulation 28 – After Inquest Template Updated 15/07/2025 TG involvement of her parents, her GP, the local Mental Health Trust, Private Counselling Services and the Police (in relation to the events causing her PTSD). Each of them had some insight into or knowledge of the nature and extent of one or more of Sarah’s conditions but none had complete oversight, or a full knowledge or awareness of all of them. Sarah had capacity, prior to the period under MHA section during her admission post-May 2024 and the evidence also showed she could be strongly opinionated and decline to admit or accept the seriousness of her situation. Allied to her likely autism and given her agoraphobia and hence difficulty in attending external appointments, the evidence was that Sarah could be ‘hard to reach’. She had received some treatment in 2010 and 2012, her GP had engaged routinely when Sarah made contact, and she had engaged latterly with programmes aimed at helping with her traumatic experiences, as well as attend some online assessments and appointments with a locum clinical psychiatrist. Overall, however, Sarah had not been able to deal with her range of conditions and/or it had not proved possible for those supporting and treating her to ensure she received sufficient, consistent and applied treatment, therapy or other care to help her recover from, adapt to or overcome her multiple difficulties. Moreover, as was admitted at the inquest, Sarah had not received appropriate, consistent mental health care in the 2 years before she died. In terms of her actual death, the historical matters giving rise to her PTSD re-emerged in late 2023 when Police were notified that a graphic account, clearly relaying criminal acts and abuse within a personal account of events, had been posted on a popular online forum for mothers. The moderators referred this as a matter of concern to the Police who investigated and identified that one linked IP address was assigned to a device on the home network at Sarah’s parents’ house. Police attended and made enquiries. It emerged that an unknown individual had cut, pasted and embellished a personal post by Sarah on a PTSD-related forum a year earlier, but Sarah confirmed that the essential facts were those which had occurred to her. Police, rightly and understandably, wished to make further enquiries, whilst acknowledging the historic nature of the events. The prospect of a criminal investigation appears to have caused Sarah extreme anxiety and concern, exacerbating her existing mental and physical health conditions, such that she stopped eating and drinking for 2 weeks before, eventually, her GP and parents were able to persuade her to be taken by ambulance to hospital. Despite extensive treatment over three months she sadly died. 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: Whilst I heard evidence that local Mental Health (MH) Services (the Sussex Partnership Foundation Trust) had aimed to ensure the recognised ‘triangle of care’ (MH Services, Individual and Family) was in place, this did not (and I understand that national policy and approach may not) extend to other services such as the GP, private counselling, or e.g. social services being formally involved and engaged in a comprehensive assessment and hence effective package of treatment and care. I fully appreciate that there are ethical, legal and patient confidentiality issues in patient care. Regulation 28 – After Inquest Template Updated 15/07/2025 TG Without, first, better information sharing and a wider, collaborative and joined-up approach – ideally with one individual [whether MH clinician, GP or even carer/family member] able, empowered and with the right legal authority to ensure they have a comprehensive and detailed knowledge of the individual’s various issues – and, second, the development of policy, protocols and guidance to better safeguard mental health patients with accompanying physical health issues, especially those who may have capacity and are neuro-diverse, there is a risk of patients like Sarah not receiving the right, consistent and individually tailored care and treatment which may prevent self-neglect or other serious self-harm. I also heard evidence that there is, nationally, a move away from traditional in-person or face to face appointments as standard and regular practice, to the increased use of online platforms and tools enabling remote attendance. I completely recognise that there are huge benefits in the use of such systems, which bring savings, efficiency and immediacy of access for a huge number of patients. My concern is that they work for some but not all. I was encouraged by evidence I heard from SPFT that in their development of a Care Plan Approach and the inception of Community Mental Health Teams there will be a local policy requirement for MH Practitioners to see patients in person at least six monthly. Sarah’s case graphically demonstrated that there is no substitute for physically seeing a patient, especially when there are other conditions and lifestyle issues so clearly impacting on or resulting from her mental health, such that it seems that an agreed national approach and similar policy requirement may also further help to prevent future deaths of patients like Sarah. 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 December 06, 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 Chief Executive of Sussex Partnership NHS Foundation Trust (SPFT) Willow Green GP Practice, East Preston, West Sussex (Parents) I have also sent it to The Royal College of General Practitioners who may find it useful or of interest. 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 15/07/2025 TG The Chief Coroner may publish either or both in a complete or redacted or summary form. They may send a copy of this report to any person who they believe 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: 11/10/2025 Joseph TURNER Area Coroner for West Sussex, Brighton and Hove Regulation 28 – After Inquest Template Updated 15/07/2025 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.
Parliamentary Under-Secretary of State for Women’s Health and Mental Health 39 Victoria Street London SW1H 0EU 15 January 2026 Mr Joseph Turner Coroner Woodvale Lewes Road Brighton BN2 3QB Dear Mr Turner, Thank you for your Regulation 28 report of 11 October 2025 sent to the Secretary of State about the death of Sarah Louise Healey. I am replying as the Minister with responsibility for mental health, and I am grateful for the additional time you have allowed for me to do so. Firstly, I would like to say how saddened I was to read of the circumstances of Ms Healey’s death, and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. Your report raises concerns over the triangle of care model not including wider services, resulting in a lack of comprehensive assessment and effective care planning; the need for a more collaborative, joined-up approach between services; and the lack of a national policy requiring regular face-to-face reviews. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. Regarding your concerns around the care model not including wider services, NHS England has advised me that it continues to support systems to improve care for people with severe mental health problems needing help from secondary mental health services, and will shortly publish new guidance, the Personalised Care Framework. This guidance will set out the core aspects of care for people who require help from secondary or integrated primary, voluntary, community and social enterprise and secondary care mental health services. This has already been shared as a draft with systems to facilitate early adoption. This new guidance will also set out the core principles that all people using NHS- commissioned community mental health, crisis and inpatient services should: • have a care and support plan that is current and that is reflective of the needs of the person at that point, and is developed with the service user, involving their carer or family member when needed, as agreed with the service user; • have a person within the service responsible for their care and support plan and for developing a trusted therapeutic relationship; • be able to have their care and support plan reviewed when things change, as well as be able to quickly re-access help when they need to (such as when their mental health deteriorates following a period of stability). This work builds upon the groundwork laid through the increased investment in transforming services as part of the NHS Long Term Plan, alongside the development of new waiting times measures for accessing community mental health services. As your report has highlighted, better integration is needed between physical and mental health care provision. Through our 10-Year Health Plan, we are delivering a shift from hospital to community. As part of this, we have launched the National Neighbourhood Health Implementation Programme. Neighbourhood Health Services will bring together teams of professionals closer to people’s home - nurses, doctors, social care workers, mental health professionals and more – to work together to provide comprehensive care in the community. This will support systems across the country by driving innovation and integration at a local level, to accelerate improvements in patient outcomes and satisfaction and ensuring care is more joined-up, accessible, and responsive to community needs. I note that Ms Healey was suffering with avoidant restrictive food intake disorder (ARFID), among other conditions. The Department is working with NHS England to improve community-based eating disorder services, including crisis care and intensive home treatment. These improvements are aimed at boosting recovery, reducing relapse, preventing eating disorders from continuing into adulthood and, where admission is required as a last resort, reducing lengths of stay. NHS England continues to work with eating disorder services and local commissioners to improve access to treatment, including for those presenting with ARFID. Regarding your concerns around the lack of national policy on conducting face to face appointments, while we aim to deliver a shift from analogue to digital through the 10-Year Health Plan, we recognise that, for some patients, in-person appointments are needed. I understand that community mental health teams often provide face-to-face assessments and follow-up reviews based on individual need, and NHS guidance for mental health services (such as NHS Talking Therapies) states that services should offer a choice of in- person or remotely delivered therapies, although the primary consideration is always the clinical appropriateness of the care, and the clinician’s professional opinion will be central to the decision. In addition, if an individual has a disability, a mental health condition, or any other impairment that makes remote appointments difficult, the NHS has a duty to make reasonable adjustments under the Equality Act 2010, which can include providing face-to- face care. However, generally speaking, the availability of in-person appointments is determined locally and there are currently no plans to develop national policy on that issue. I hope this response is helpful. Thank you again for bringing these concerns to my attention. Yours sincerely, PARLIAMENTARY UNDER-SECRETARY OF STATE FOR WOMEN’S HEALTH AND MENTAL HEALTH
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