Naomi Aylott

25 November 2025 

Mr Robert Simpson 
HM Assistant Coroner  
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 Simpson 

Please find enclosed the Trust’s response to the Regulation 28 report issued following the inquest into 
the death of Naomi Aylott.  

I am grateful for your considered observations regarding this case and 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 Executive 

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 

 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1.  I am concerned that Naomi was never seen face to face by her care coordinator over the 3 – 4 
month period that she was under the care of the CMHT. I heard evidence that the Andover 
CMHT, in particular, was impacted by a change in the way that primary care networks (PCNs) 
refer patients to secondary services. Due to Naomi’s GP surgery being within a particular PCN 
she was referred to the Andover CMHT even though she lived in Four Marks, a 40-50 minute 
drive from Andover. This is much further than would have been the case had Naomi come 
under the care of the Winchester CMHT. The Andover CMHT has not been able to arrange as 
many face to face appointments with care co-ordinators due to the time they would have to 
spend travelling. Naomi’s care was not referred to the Winchester CMHT originally nor was it 
transferred from the Andover to the Winchester CMHT after the referral was accepted. 

Although many patients prefer technology-based consultations—and research supports their 
effectiveness as a therapeutic delivery method—a blended approach that combines face-to-
face and remote contact is generally considered the most effective way to manage risk.  

In situations where patients live a considerable distance from the team base, remote 
consultations have become more common. This shift is driven both by pressures on staff time 
and by the inconvenience patients face when they have a lengthy journey to their outpatient 
appointments, which leads them to favour remote options.  

The Andover CMHT in particular, does cover a large geographical area and we recognise that 
this poses a logistical challenge for patients to be seen face to face. This has arisen as a result 
of the catchment area being defined by the externally allocated Primary Care Networks. We 
accept that this is not ideal and are actively taking steps to address this so that patients living 
in more rural parts of the area, as Naomi was, can instead be seen by staff based at a 
Winchester clinic. I expect these new ways of working to be fully implemented by January 
2026. 

2.  I am concerned that within the Andover CMHT the training around risk assessments and the 

auditing of compliance with risk assessment policy is not adequate. In relation to Naomi I heard 
evidence that the completion of formal risk assessments was not carried out in accordance 
with the CMHT policy. I heard evidence that Andover CMHT had undergone risk assessment 
training at around the time they were involved in Naomi’s care. Despite this no formal risk 
assessments were completed. In addition I heard that the process for auditing risk assessment 
compliance had not identified this failure in respect of Naomi’s care.  I also heard evidence that 
the Andover CMHT had requested further training from the Hampshire and Isle of Wight Trust 
but that this had not taken place. 

Whilst staff in the CMHT were reviewing Naomi’s risks on an ongoing basis, we accept that the 
risk assessment documentation was not updated to reflect this. 

Regarding training, the witness at the inquest has clarified that they inadvertently gave you 
incorrect information when giving their evidence. They had stated that the risk training provided 
to the CMHT coincided with the care provided to Naomi, when in fact it was delivered 
afterwards as part of the improvement work undertaken with the team following Naomi’s death.  

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 By way of some context, 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.  

There is an onus on registrants to take responsibility for remaining competent in their area of 
practice as clearly set out in the Nursing and Midwifery Council’s Code of Conduct. Trust staff 
are supported by relevant policies and guidelines on risk management and also have access to 
supervision and the wider multidisciplinary processes which are additional key components in 
supporting staff with the management of risk. 

To ensure that they are as confident as possible in this field, a formal programme of risk 
management training has recently been developed for staff working in mental health services. 
This will standardise the offering across the organisation and will act as a refresher for staff. 
The roll out will commence in quarter 4 of 2025/26 with a ‘train the trainers’ approach, followed 
by a full programme of training delivery starting in quarter 1 of 2026/27. 

The main focus of the training will be the need to move away from stratification of risk into ‘low, 
medium and high’, which has historically been widely embedded in mental health language, as 
this is considered to be ineffective in its determination of risk. The training programme will 
cover the evidence base for this different approach, which is in keeping with the NHS England 
guidance ‘Staying Safe from Suicide: Best practice guidance for safety assessment, 
formulation and management (April 2025). There will also be an emphasis on involving ‘trusted 
others’, whilst needing to balance this with the patient’s right to confidentiality.  

There will be time dedicated to practical exercises to ensure there are chances for practitioners 
to consider what a formulation may look like, what the 5 P’s (Precipitating, Predisposing, 
Perpetuating, Protective and Presenting Factors) are and how they build the narrative around 
the nature of someone’s risk/safety picture. The training will also look at what safety planning 
should incorporate and again work from the foundation that this is done in collaboration with 
the patient and ideally their family/carers. 

There is also recognition that in order to support this training programme, our electronic patient 
record system will need updating such that it supports the recording of staff observations 
around risk using this new approach. 

Pending the roll out of our new risk management training programme, community mental 
health teams (including Andover) have received bespoke risk management training sessions 
delivered on a team-by-team basis at their local team base.  

Routine audit of compliance has also been standardised across our organisation’s community 
mental health teams with the introduction of a revised Quality Assurance Tool in November 
2025, which has been designed to specifically target the quality of risk assessments being 
completed. This is a Trust-wide approach and is much more sensitive to identifying shortfalls 
across our Mental Health Services and allowing remedial action to be taken. 

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 3.  I am concerned that the Andover CMHT do not appear to have considered how to keep a 

person’s family involved in their care (when there is the appropriate consent to do so) when 
meetings with the care co-ordinator take place over the phone and not face to face. 

We understand the particular concerns identified here with regards to how to involve families 
when care is delivered remotely, and we accept that this ought to have been better considered 
in Naomi’s case. This challenge also arises when patients attend face to face appointments in 
a clinic setting as they often will do so alone, without accompanying family.  

To provide some context, in the Trust’s mental health services alone, there were over half a 
million patient contacts in the community in the 12 months to the end of October 2025. There is 
evidence of positive family engagement in many of these services but 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. 

Below is a summary of some of the work we have undertaken in this area which we will 
continue to embed and monitor. We have also had external scrutiny from our internal auditors 
which is also summarised.  

Collaboration with Partners and other Organisations 

We work collaboratively and in partnership with a number of carer organisations and partners 
such as Hampshire Carers together.  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. 

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 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.  

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 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. 

Independent assessment of Trust performance in this area 

In 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.  

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’. 

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 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. 

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