Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0584, written 17 Nov 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Nov 2025 |
|---|---|
| Reference | 2025-0584 |
| Deceased | Ethel Robertson |
| Coroner | Nicholas Walker |
| Coroner area | Hampshire, Portsmouth and Southampton |
| Category | Suicide (from 2015) |
| 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: 1 Southern Health Foundation Trust (Legal) 1 CORONER I am Nicholas WALKER, HM Area Coroner for the coroner area of Hampshire, Portsmouth and Southampton 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 01 March 2024 I commenced an investigation into the death of Ethel Mitchell ROBERTSON aged 79. The investigation concluded at the end of the inquest on 20 October 2025. The conclusion of the inquest was that: Ethel died from the consequences of an intentional overdose which she took to end her life. A conclusion of suicide was reached. 4 CIRCUMSTANCES OF THE DEATH Ethel had a long history of depression and anxiety which was made worse by chronic alcohol consumption and she had, since 2014, taken intentional drug overdoses on eleven occasions. Her care was managed by her GP and the Older Persons Mental Health Service [OPMH], part of NHS Southern Health NHS Foundation Trust. Ethel would attend hospital emergency department [ED], as she had a few weeks before her death when she presented at Queen Alexandra Hospital in Portsmouth after an apparent accident. She was found deceased at home on 18th February 2024. 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: (brief summary of matters of concern) An Area Matron at the Older People’s Mental Health Service [OPMH] gave evidence that the service is not routinely informed when one of their patients is admitted to or discharged from ED. If the presentation at the hospital was for a mental health related issue, then the OPMH team is likely notified as there will be contact with the psychiatric liaison service in the hospital. However, if the presentation is for something not related to mental health, the OPMH will not be notified as clinicians within the ED do not have access to the computer systems operated by service providers in the community. I am concerned that OPMH will not know if one of their patients has had a physical health Regulation 28 – After Inquest Document Template Updated 30/07/2021 crisis which could precipitate a decline in their mental health or has presented with something that those not familiar with the patient might fail to appreciate is linked to their metal health. I am concerned that this will have serious implications for patient safety and could delay appropriate follow-up, risk management and decision-making. It also places an added pressure on those in primary care to have systems in place to alert the community teams when they receive discharge documentation from ED. 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 12, 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 I have also sent it to 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. 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: 17/11/2025 Nicholas WALKER HM Area Coroner for Hampshire, Portsmouth and Southampton Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
23rd December 2025 Nicholas Walker HM Area 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 Walker, Regulation 28: Report to Prevent Future Deaths arising from the Investigation and Inquest relating to Ethel Mitchell Robertson – 20thOctober, 2025 The concern you raise is that if an elderly person attends an Emergency Department for non mental health issues, then that information is not necessarily available to the Older People’s Mental Health Service. The main issue is not that the services operate on different computer systems, but rather the raising of a flag for the professionals in the Older People’s Mental Health team. In each of the Emergency Departments across Hampshire, there are effective Mental Health Liaison Teams, each of which works with the Emergency Department. When an adult, of any age, demonstrates signs of mental ill health when in the Emergency Department, the liaison teams are in a position to notify the Community Mental Health Team, or the Older Person’s Mental Health Team. However, to check every patient attending the Emergency Departments for physical health conditions as to whether or not they also have a mental illness is not practical. Some people with mental illness also have objections to their mental health records being shared more widely. Even with connected computer systems, the additional workload of checking every patient to establish whether they have mental health issues is disproportionate to the small number of cases where the mental health conditions are not evident to the clinicians in the Emergency Department. If you would find a discussion helpful, I would be very happy to arrange. Yours sincerely Chief Executive 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
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