Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0571, 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 | 2025-0571 |
| Deceased | Joanna Chamberlain |
| Coroner | Joseph Turner |
| Coroner area | West Sussex, Brighton and Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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: , 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 23rd January 2025 I commenced an investigation into the death of Joanna Chamberlain. The investigation concluded at the end of the inquest on 7 November 2025. The conclusion of the inquest was that on 23rd January 2025, Joanna Chamberlain was found suspended from a ligature at her home address in Hassocks, West Sussex. Emergency services attended but, despite CPR, Joanna was sadly declared to be deceased at the scene. Joanna had experienced suicidal thoughts for many months and had made several previous attempts, but had not been assessed as high risk, in part because no input was sought or received from her family. Her significant physical health conditions more than minimally contributed to her poor mental health. She took her own life also in part because her overwhelming and longstanding mental health issues had never been fully or successfully treated. 4 CIRCUMSTANCES OF THE DEATH The day before her death, Joanna attended clifftops near her home with the intention of jumping but had drawn back and contacted her GP as well as attend a pre-planned assessment with a locum clinical psychiatrist at her local mental health assessment and treatment service unit. The GP contacted the mental health team to ensure Joanna was seen urgently. Notwithstanding the events of earlier in the day, which followed a recent overdose and other incidents of self-harm involving makeshift ligatures around her neck, the assessment was that Joanna was at moderate risk. The assessment was made largely on Joanna’s immediate presentation, with reference to care notes but no other 3rd party (e.g. GP) or family input. Whilst a period in a 24 hour ‘Haven’ crisis facility was considered, the plan agreed with and by Joanna was for her to return home, where the presence of her husband and son were powerful protective factors, and receive daily input and support from the Crisis Resolution Home Treatment Team (CRHTT). Joanna had previously been in their care. Joanna did not want to enter a unit as a voluntary patient and nor was this deemed necessary. Joanna duly returned home, to the great surprise and concern of her husband who had strongly expected her to have been admitted to residential care and treatment. After lengthy discussion with Joanna, he was reconciled to the immediate plan but both he and Joanna felt and hoped the team’s visit the next morning may initiate the process for her to be a voluntary in-patient, despite previous reluctance. Joanna had withdrawn consent for her confidentiality to be waived as regards her husband Regulation 28 – After Inquest Template Updated 15/07/2025 TG 2 days earlier, for fear of her condition and the involvement of mental health services adding to his stress and burden. Even during the periods where she had given consent, however, at no time had he been consulted or included in her care plan. Moreover, at no time had he been informed that, outside and separate to the confidentiality of Joanna’s care, he could have voluntarily provided information and input to the teams involved. Partly due to the financial pressures on the family occasioned by Joanna’s incapacity for work due to her physical and mental conditions, and in the hope and expectation that the CRHTT would attend, further assess Joanna and help, her husband left for work early the following morning, before the planned attendance of the CRHTT at 10 am. Sadly, this removed a powerful protective factor and Joanna took her own life before the team attended at her address. 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 am keenly aware that it is not for Coroners to investigate matters of national public policy or resource, there appears to be a local and national gap in the provision of safe and supportive spaces, where clinical help and care can be given to mental health patients who may not be in immediate crisis yet who would benefit from more support than can be given by home treatment teams. Or whose risk assessment suggests may benefit when protective factors change or are temporarily unavailable at certain times of the day or night. Equally, whilst I recognise the importance and value in clinicians rapidly assessing a patient’s risk of self-harm, using their individual professional judgement, and forming an immediate care and safety plan, there is a potential need for clearer national guidance on, direction to and protocols for clinicians to proactively seek and include the views and input of family members, or others (e.g. GP), reinforcing the triangle of care, and especially where the delivery or assurance of a care and safety plan depends on them. This appears even more necessary where such individuals themselves are a key protective factor. 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 January 02, 2026. 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, Sussex Partnership NHS Foundation Trust 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: 10/11/2025 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.
Joseph Turner
Area Coroner for West Sussex, Brighton and
Hove
Record Office,
Orchard Street,
Chichester
PO19 1DD
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
6th January 2026
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Joanna Chamberlain who
died on 23rd January 2025.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 10th
November 2025 concerning the death of Joanna Chamberlain on 23rd January 2025.
In advance of responding to the specific concerns raised in your Report, I would like
to express my deep condolences to Joanna's family and loved ones. NHS England is
keen to assure the family and yourself that the concerns raised about Joanna’s care
have been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise for
any anguish this delay may have caused Joanna’s family or friends. I realise that
responses to Coroners’ Reports can form part of the important process of family and
friends coming to terms with what has happened to their loved ones, and I appreciate
this will have been an incredibly difficult time for them.
Your Report raised concerns that there is a gap in the provision of supportive spaces
for mental health patients, who are not in immediate crisis but may benefit from more
support than that provided by home treatment teams. You were also concerned that
there is a need for clearer national guidance for clinicians to proactively seek views
and input from family members or others in forming an immediate care and safety plan
for the patient.
24/7 Neighbourhood Mental Health Centres
Six areas of the country are trialling neighbourhood mental health centres to provide
community support to people with serious mental illness. The neighbourhood centres
are being implemented in the following locations:
• Copeland (Whitehaven)
• Acomb (York)
• Heeley (Sheffield)
• Birmingham East Central
• Tower Hamlets (London)
• Lewisham (London)
The centres will be open 24 hours a day and 7 days a week, bringing together all
aspects of community mental health services, which could include crisis services and
short stay beds depending on the needs of their local area.
Anyone with serious mental health needs can drop into the centre without an
appointment to receive support from psychiatrists, mental health professionals, social
workers, voluntary sector workers and peer support workers.
These centres will enable people to receive psychological therapies, medication and
other interventions, while also having access to expertise that can help with other
important issues that may impact on their wellbeing and recovery, such as housing or
employment. Evidence shows that continuity of care and being supported by the same
team, who you trust and know, is critical for people’s recovery in mental health care.
The centres will be run in partnership between the NHS and a range of local colleagues
in health and social care, including voluntary, community, and social enterprise
(VCSE) sector organisations and critically, in partnership with people with lived
experience. The model of care provided through these new centres is recommended
by the World Health Organization.
There are also sixteen associate site who are in receipt of the formal implementation
support offer from NHS England however not additional funding. These sites include:
• Blackpool Central
• Ellesmere Port
• South Stafford
• South East Telford
• Northampton Central
• South Somerset West
• Brixham & Paignton
• East Lincolnshire
• New Parks
• Hinckley & Bosworth
• Alfreton & Ripley
• Stonebridge
• Bletchley
• North Islington
• South Leytonstone
• Portsmouth North
• Andover
Community Mental Health Framework
Since the publication of the Community Mental Health Framework (2019), it has been
national policy that all Integrated Care Boards (ICBs) build stronger relationships with
both local authorities and VCSE organisations as part of the wider transformation of
services for people with severe mental health problems. VCSE providers are well
placed within communities to provide support to meet the social needs of people with
Severe Mental Illness (SMI), supporting people to manage their condition or move
towards individualised recovery on their own terms in their local community.
Furthermore, VCSE organisations, particularly grassroots organisations, have a key
role to play in reaching previously underserved communities, thereby advancing
equalities in access, experience and outcomes.
Examples of partnership working with VCSE partners include Open Mental Health in
Somerset - an alliance that consists of nine core VCSE organisations, nine associate
VCSE organisations, and a wider network of over 80 diverse small and micro VCSE
organisations that have received small grant funding. The offer from Open Mental
Health can include support around money, benefits and debt; support to be socially
connected; community crisis support; 1:1 and group peer support; telephone support
including a specialist service for older people and a 24/7 VCSE-led helpline; alongside
clinical interventions delivered by the NHS.
Meanwhile, Everyturn Mental Health in Northumberland are commissioned by the local
ICB to provide community based alternatives to crisis pathways, including safe havens
and crisis beds. The service provides a practical and holistic approach to help people
with a range of psychological stressors that can lead them into crisis.
NHS England published the Staying Safe from Suicide: Best Practice Guidance for
Safety Assessment, Formulation and Management on 4 April 2025. It promotes a shift
towards a more holistic, person-centred approach rather than relying on risk
prediction, which is unreliable because suicidal thoughts can change quickly. Instead,
it recommends using a method based on understanding each person’s situation and
managing their safety. One of its 10 overarching principles of approach is that of
'involving others: encourage the involvement of trusted others, where possible and as
appropriate'. The guidance applies to all mental health practitioners and promotes the
proactive engagement of trusted others within legal limits, highlighting that "in the case
of immediate risk to life, the duty to share information overrides confidentiality". This
guidance therefore clarifies previous national guidance.
NHS England has also launched an e-learning session, which is designed to
complement our Staying Safe from Suicide Guidance. The Staying Safe from Suicide:
Best practice guidance e-learning session is now available for all mental health
practitioners across the country. The guidance and the training both cover sections on
confidentiality and the law, and refer to the Consensus statement for information
sharing and suicide prevention.
The Medium term planning framework - delivering change together 2026/27 to
2028/29 also mentions that, in 2026/27, ICBs must 'ensure mental health practitioners
across all providers undertake training and deliver care in line with the Staying safe
from suicide' guidance.
Personalised Care Framework
NHS England has shared draft guidance with ICBs which emphasises the importance
of involving a person's family, carers or support network in planning and reviewing the
care for people with severe mental health problems. This 'Personalised Care
Framework' includes a dedicated section on the safety planning and the management
of risk (including where there are risks of harm to self).
Local Improvement Work
After reviewing this case, Sussex Partnership NHS Foundation Trust have outlined the
work they are undertaking to improve the offer of community-based home treatment.
This includes:
• Strengthening the 111 & Blue Light Line (999) services by recruiting additional
staff and expanding access to senior and expert mental health practitioners.
• Establishing a 24/7 crisis response team and increasing access to staying well
•
services.
Increasing the number of beds by commissioning short-term independent
sector beds to provide immediate relief while system-wide improvements are
embedded.
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
Joanna, 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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