Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2026-0013, written 1 Dec 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Dec 2025 |
|---|---|
| Reference | 2026-0013 |
| Deceased | Amy Pugh |
| Coroner | Paul Marks |
| Coroner area | East Riding and Hull |
| Category | Alcohol, drug and medication related deaths · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Humber Teaching 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (Chair) 1. NHS England – 2. 3. 4. 5. 6. 7. 8. 9. 10. 1 CORONER I am Professor Paul Marks, Senior Coroner, for the Coroner Area of City of Kingston Upon Hull and the County of the East Riding of Yorkshire. 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 July 2024, I commenced an investigation into the death of Amy Grace Pugh, aged 23 years. The investigation concluded at the end of the inquest on 26th November 2025, the narrative conclusion of the inquest was:- Amy Grace Pugh took an overdose of and other drugs around midnight on 10th April 2024 which resulted in her death on the morning of 11th April 2024. Whilst it is certain she took the drugs, it is not possible to discern her intent. 4 CIRCUMSTANCES OF THE DEATH Amy Grace Pugh had a complex psychiatric history comprising emotionally unstable personality disorder, post-traumatic stress disorder, attention deficit hyperactivity disorder, anxiety and depression as well as drug and substance misuse. She had a proclivity to self-harm and taking overdoses of medication. 1 She received a custodial sentence of 18 months imprisonment which she served at HMP Low Newton and was released on 27th March 2024. Whilst in prison two Assessments, Care in Custody and Teamwork (ACCT) were opened and subsequently closed. The ACCT's were opened due to self-harming behaviour whilst in custody. On her release she was inadequately supported by various agencies and the combination of this lack of support resulted in the recurrence of self-harming behaviour and a serious deterioration in her mental health, which had been stable during the latter part of her incarceration. Two hospital attendances resulted from applying a ligature to her neck and later the same day, 3rd April 2024, from a combined overdose of medication and consumption of alcohol. She required elective ventilation in the intensive care unit of Scunthorpe Hospital until the effects of alcohol and drugs had passed off. On regaining consciousness on 5th April 2024, she displayed psychotic symptoms and was detained under 5(2) of The Mental Health Act 1983. Despite this, she absconded from hospital but was returned the same day. She underwent a mental health assessment on 8th April 2024 which resulted in her informal admission to Avondale Unit in Hull. She obtained leave on 10th April 2024 to visit her twin sister in York. Whilst in the company of her sister, she appropriated her sister's drugs which comprised pregabalin, diazepam, gabapentin, codeine and propranolol. She returned as scheduled to the Avondale Unit on 10th April and queries were raised around 21:00 hours that she might be intoxicated. She denied this. At 22:00 hours she collapsed in the garden of the facility and lost consciousness but recovered after about 2 minutes. Paramedics were called and attended, by which time she was fully conscious with essentially normal vital signs. Out of an abundance of caution, paramedics advised that she should go to hospital to be checked, but Amy refused and the default position was that staff of the Avondale Unit would observe her overnight. Observations were conducted at 01:00 and 02:00 hours visually through a flap in the door of Amy’s bedroom with neither entry into the room or physical examination being carried out. In all the circumstances, this was an inadequate means of assessing Amy. At 03:00 hours, a further observation occurred, this time with entry into Amy's room. She had no pulse, was not breathing and had fixed, dilated pupils. Despite cardiopulmonary resuscitation being carried out, there was no return of spontaneous circulation, and she was declared deceased at 04:13 hours at Hull Royal Infirmary. The aggregation of failings in this case may be considered to have more than minimally, negligibly and trivially resulted in Amy's death. 2 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. – Following Amy’s admission to Avondale Unit on 8th April 2024, clinical staff were unable to access important records pertaining to Amy’s mental health from partner NHS mental health institutions and this compromised her assessment and subsequent management. The approved findings of fact are attached. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation has the power to take such action. This may include, for example, ensuring that medical records systems within the NHS are compatible, can be accessed 24 hours per day by partner organisations and hence permit the data systems to “talk to each other.” YOUR RESPONSE 7 You are under a duty to respond to this report within 56 days of the date of this report, namely by 9th March 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Next of Kin, Humber NHS Mental Health Trust, Government Legal. I am also sending a copy to NHS England and equivalent organisations in the other countries of the United Kingdom. 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 12th January 2026 3
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.
Professor Paul Marks
Senior Coroner,
City of Kingston Upon Hull
and the County of the
East Riding of Yorkshire
Coroner’s Service
The Guildhall
Alfred Gelder Street
Hull
HU1 2AA
Dear Coroner,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
2nd March 2026
Re: Regulation 28 Report to Prevent Future Deaths – Amy Grace Pugh who
died on 11th April 2024.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 12th
January 2026 concerning the death of Amy Grace Pugh on 11th April 2024. In advance
of responding to the specific concerns raised in your Report, I would like to express
my deep condolences to Amy’s family and loved ones. NHS England is keen to assure
the family and yourself that the concerns raised about Amy’s care have been listened
to and reflected upon.
Your Report raised concerns that clinical staff at the Avondale Unit in Hull (falling under
the Humber Teaching NHS Foundation Trust) were unable to access important
records pertaining to Amy’s mental health from partner NHS mental health institutions,
which compromised her assessment and subsequent management.
NHS England is committed to improving the maturity and quality of Electronic Patient
Records (EPRs) across all NHS Trusts. NHS England has provided funding to ensure
all NHS Trusts have an EPR implemented. It is, however, up to individual NHS Trusts
to effectively procure and implement their chosen EPR system, and to agree and
progress any convergence of EPR systems within their local systems.
NHS England is also committed to supporting the sharing of critical clinical information
across NHS organisations. Historically, different care settings have adopted different
clinical systems to maintain a clinical record; some areas have adopted the same
electronic patient record (other areas have adopted shared care records which can
provide access to records from different care settings).
I have been advised by NHS England’s Frontline Digitisation Team that the Humber
Teaching NHS Foundation Trust (formerly Humber NHS Mental Health Trust) reported
that it had completed procurement to implement TPP SystmOne as a single, integrated
EPR solution across both physical and mental health services within the Trust. The
implementation was reported as successfully completed in 2025; prior to this the Trust
had been using a different EPR system known as Lorenzo since 2012.
I am also advised that the Humber Teaching NHS Foundation Trust are connected to
the Yorkshire and Humber Shared Care Record (YHCR) which should enable the
sharing of patient information across the region. All staff at the Trust have access to
the YHCR. GP Connect, which is accessible via the YHCR, provides information from
Primary Care providers.
In addition, the National Care Records Service (NCRS) enables access to the patient’s
Summary Care Record (SCR), which was accessible by the Trust through Lorenzo in
2024 and through TPP SystmOne since 2025. In the event that the patient is not able
to provide ‘Permission to View’ their SCR, an emergency access option is available to
clinicians. Additional information is also available on the SCR which may include
further medical information.
The newly published Fit for the future: 10 Year Health Plan for England sets out the
government’s plan for healthcare in England over the next 10 years. The plan sets out
a commitment to give patients ‘a single, secure and authoritative account of their data
– a single patient record – to enable more coordinated, personalised and predictive
care.’
NHS England is aware of the challenge in sharing medical records between providers
and the variability between areas using different technologies. We are also aware that
use of the SCR is variable across different care settings. We are therefore working
across the health system to support greater integration and awareness of record
sharing between providers. We are also working with the SCR Programme to support
wider access to relevant patient information.
NHS England recognises the critical importance of improving data sharing between
NHS organisations to support coordinated patient care. The 10 Year Plan commits to
harnessing the digital revolution to enable more coordinated, personalised and
predictive care. The Medium-Term Planning Framework (2026/27 to 2028/29)
reinforces this ambition, with services becoming digital by default and integrated
neighbourhood teams having access to digital tools and shared care records. This
shift towards interoperable technology will support better communication and
information sharing between NHS providers, helping to ensure safer, more joined up
care for patients.
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 Amy,
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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