Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0589, written 18 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 | 18 Nov 2025 |
|---|---|
| Reference | 2025-0589 |
| Deceased | Lynsey Dearden |
| Coroner | Emma Serrano |
| Coroner area | Staffordshire and Stoke on Trent |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. NHS England 2. North Staffordshire Combined Healthcare NHS Trust 1 CORONER I am Emma Serrano, Area Coroner, for the coroner area of Staffordshire and Stoke on Trent. 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 the 12th March 2025, I commenced an investigation into the death of Mrs Lynsey Ellen Dearden. The investigation concluded at the end of the inquest on 18 November 2025. The conclusion of the inquest was a short form conclusion of suicide. The cause of death was: 1a) Asphyxiation 1b) II) Anxiety and depression 4 CIRCUMSTANCES OF THE DEATH i) Mrs Dearden was found deceased, on the 11 March 2025, at her home address . 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1. Evidence emerged during the inquest that Mrs Dearden was allocated a Community Psychiatric Nurse, and key worker in November 2024 but had not received any appointments to the date of her death on the 11 March 2025. There was no real explanation as to why, or any policy or procedure to give a framework as to how or when appointments should take place; 2. Evidence emerged during the inquest that Mrs Dearden was allocated a Community Psychiatric Nurse, on the 31st December 2024, to facilitate a standard assessment framework, to assess what help and treatment Mrs Dearden may need in the community. This did not take place, and there was no answer as to when this should have taken place, or how this should have been carried out as there is no policy, guidance or framework in place to govern this. 1 [IL1: PROTECT] 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 13 January 2026. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; 1. The family of Lynsey Dearden. I am also under a duty to send the Chief Coroner a copy of your response. 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 18 November 2025 Miss Emma Serrano Area Coroner Staffordshire 2 [IL1: PROTECT]
2 responses 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.
Emma Serrano
Area Coroner for Staffordshire and Stoke on Trent
Stoke on Trent and North Staffordshire Coroners Service
Stoke Town Hall
Kingsway
Stoke-on-Trent
ST4 1HH
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 – Lynsey Ellen Dearden who
died on 11th March 2025.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 18th
November 2025 concerning the death of Lynsey Ellen Dearden on 11th March 2025.
In advance of responding to the specific concerns raised in your Report, I would like
to express my deep condolences to Lynsey’s family and loved ones. NHS England is
keen to assure the family and yourself that the concerns raised about Lynsey’s care
have been listened to and reflected upon.
Your Report raised concerns that there is no policy, guidance or framework in place
for how or when appointments with community psychiatric nurses, including standard
assessments, should take place.
NHS England continues to support systems to improve care for people with mental
health problems needing help from secondary mental health services. NHS England
has shared draft guidance with systems, the Personalised Care Framework, that sets
out the core aspects of care for people who require help from secondary or integrated
primary care services, the Voluntary Community and Social Enterprise (VCSE) and
secondary care mental health services. The draft has been shared to facilitate early
adoption.
The guidance sets 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;
• 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 builds upon the groundwork laid through the increased investment in services,
alongside the development of new waiting times measures for accessing community
mental health services. NHS England also continues to work with systems to improve
the data quality of the Mental Health Services Data Set (MHSDS) submissions for this
measure, which records how many people receive meaningful help within 4 weeks of
referral.
North Staffordshire Combined Healthcare NHS Trust have informed NHS England’s
Midlands regional team that they have identified improvements as a result of this
Report, which they will outline in their separate response to you. However, they have
detailed the immediate actions they have taken, which include a process to contact
patients awaiting Standard Assessment Framework assessments, a requirement that
key workers are not allocated until an appointment date is confirmed, and clarification
of timescales and expectations for transition between teams.
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
Lynsey, 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
Date: 13th January 2026 Emma Serrano Area Coroner Staffordshire and Stoke-on-Trent Coroners Office Swann House Boothen Road Stoke-on-Trent, ST4 1SY Chief Medical Officer Lawton House (HQ) Bellringer Road Trentham Lakes South ST4 8HH Dear Mrs Serrano Re: Prevention of Future Deaths – Lyndsey Dearden – Issued 18th November 2025 I am writing to provide you a response to the Regulation 28; Prevention of Future Deaths (PFD) report which was issued to the Trust on 18th November 2025. This response is intended to outline the Trusts key areas of focus for improvement and to offer additional assurance regarding the learnings taken. The PFD report identifies two principal concerns: 1. Lack of appointments post- allocation of key worker Evidence presented at the inquest indicated that Mrs Dearden was allocated a Community Psychiatric Nurse (CPN) and key worker in November 2024 but did not receive any appointments prior to her death on 11 March 2025. No clear explanation was provided why, or any policy to give a framework as to how appointments should take place. 2. A failure to complete a Standard Assessment Framework (SAF) Mrs Dearden was allocated a Community Psychiatric Nurse on 31 December 2024 to undertake a SAF assessment to determine appropriate community support and treatment. This assessment did not occur, and there was no adequate response as to when this should have taken place and how this should have been carried out as there is no policy, guidance or framework. www.combined.nhs.uk Follow us on Twitter/X: @CombinedNHS Follow us on Facebook: www.facebook.com/NorthStaffsCombined We are a diverse and inclusive Trust and there is no place in our organisation for discrimination, harassment or personal abuse Immediate actions taken: In response to the PFD and our internal review, we have implemented the following: A Practice Note issued highlighting the following, • A clear process for contacting and monitoring patients awaiting SAF assessments. • A requirement that an appointment date is confirmed at the time of allocation of key workers. • Clarification of timescales and expectations for transitions between teams (particularly between Crisis Resolution Home Treatment Team (CRHTT) and Community Mental Health Team (CMHT)). These additional processes and clarifications will be added to the Trust Care Management Policy which is currently under review. Trusts Key areas of improvement. 1. Lack of appointments post allocation of key worker Though the Trust adheres to NHSE’s requirements for 48-hour follow-up and 18-week referral to treatment metrics it is recognised that there is no national standard timeframe for assignment of a keyworker and completion of a SAF. As referenced in the PFD report, there wasn’t a clear framework outlining to NSCHT staff the expectations and timeliness of appointments when patients are transitioning from one service to another; in this case it was from CMHT to Inpatient ward through CRHTT and back into CMHT. The Practice Note already referenced has been issued to all relevant senior leads with an expectation that the improvements are immediately operational. Timeframes have been agreed and will be monitored via multidisciplinary team and assurance audits. Two initial audits have been undertaken, one prior to the Christmas 2025 and one during the second week of January 2026 to assess the adoption of the Practice Note and expected timescales. Results indicate good compliance across the Inpatient, CRHTT and CMHT services. A further audit is scheduled for 3 months’ time and 12-18 months to provide assurance that these processes have been embedded. The revised Trust Care Management policy will incorporate the audit assurance process. 2. A failure to complete a Standard Assessment Framework (SAF) The prevention of future deaths report correctly outlines that a key worker was appointed to LD shortly after her discharge from inpatient services on the 31st of December 2024, but an appointment with the key worker had not been received up to the date of LD’s death on 11 th March 2025. The Trust accepts that this is not up to the standard of high-quality responsive care and that an appointment date should have been issued to LD sooner. We have taken immediate action to address this by issuing a Practice Note to all clinical teams clarifying timescale expectations as well as reiterating that SAF is not a pre-requisite for receiving interventions www.combined.nhs.uk Follow us on Twitter/X: @CombinedNHS Follow us on Facebook: www.facebook.com/NorthStaffsCombined We are a diverse and inclusive Trust and there is no place in our organisation for discrimination, harassment or personal abuse in care. This will also be reflected in the Trust Care Management Policy currently under review. The Trust would like to offer some assurance that LD did have ongoing access and support from Trust services during this time. LD had received a hospital admission, interventions from the CRHTT. In addition, during December a Key Worker sent a letter of introduction to LD. LD also contacted the Duty Team within the CMHT in February 2025, who offered support and advice, and sign posted LD to additional community-based support. In addition, it is pertinent to explain that the Trust has undertaken work to transition to co-produced care planning and move away from Care Programme Approach (CPA) as this was a large-scale transformation project, this has been delivered in phases across the Trust. Our aim is to align all care planning to ensure coproduced person-centred care for our service users and consistency for staff when developing care plans. This will mean one way to complete care planning for all service users. Our new way of care planning is in line with the Professional Record Standards Body and was guided by the NHSE Community Mental Health Framework initially and now by the NHSE Comprehensive Model of Personalised Care, to ensure a consistent framework is being followed across the Trust. As a result of this, our staff have received care planning training which has focused on person centred care, the values of a therapeutic relationship and coproduction. We have a new Standard Operating Procedure for care planning and are drafting our Care Management Policy currently to reflect these changes in practice and guidance. Conclusion The Trust accepts the findings of the coroner and have taken urgent action to implement changes and improvements. We intend to monitor the changes via audit until we are assured that improved practice is embedded completely. Yours sincerely MBBS, FRCPsych, DPM, MSc. MBA Chief Medical Officer www.combined.nhs.uk Follow us on Twitter/X: @CombinedNHS Follow us on Facebook: www.facebook.com/NorthStaffsCombined We are a diverse and inclusive Trust and there is no place in our organisation for discrimination, harassment or personal abuse
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