Lucy Thornton

St Mary’s Hospital  
   Newport 
       Isle of Wight  
PO30 5TG 

Date: 23rd March 2026 

Private and Confidential 

Mr J Pegg 
HM Area Coroner for Hampshire, Portsmouth and Southampton 
The Coroner’s Court 
1 Guildhall Square 
Portsmouth 
PO1 2GJ 

Dear Mr Pegg, 

RE Lucy Thornton - Response to Regulation 28 Report to Prevent Future Deaths 

I  am  writing  in  my  capacity  as  Chief  Executive  of  the  Isle  of  Wight  NHS  Trust  in  response  to  the 
Prevention of Future Deaths (PFD) report issued following the conclusion of the inquest into the death 
of Ms Lucy Thornton on 27th January 2026. 

On  behalf  of  the  Isle  of  Wight  NHS  Trust,  I  would  like  to  express  our  sincere  condolences  to  Ms 
Thornton’s  family  and  loved  ones.  We  are  grateful  to  the  Court  for  bringing  these  matters  to  our 
attention, and we have carefully considered the concerns raised within your report. 

Your  report  identified  concerns  regarding  the  level  of  training  and  understanding  of  call  handling 
procedures in relation to incidents involving potential hanging or suicide. In particular: 

1.  The procedures direct a Category 1 response (7 minutes) when the person has the means to 
suspend themselves and has stated that is there present intention. The call handler believes 
that a Category 1 response is, "When they are going to die now". 

2.  The procedures direct that when the call handler does not have all relevant information, they 
should telephone the person and ask questions in relation to the person's present situation. The 
call handler was on the Isle of Wight. Ms Thornton was in Southsea. The call handler did not call 
Ms Thornton she felt she was too remote (geographically). 

In response to these concerns, a review and audit of the call established that the call handler did not 
make  sufficient  efforts,  in  accordance  with  Isle  of  Wight  Ambulance  Service  (IOWAS)  processes,  to 
make direct contact with the patient. This has been addressed with the individual concerned. 

The call handler did, however, upgrade the incident to a Category 2 ambulance response. This decision 
was based on information indicating a possible attempt at hanging and a lack of clarity regarding the 
extent of bleeding. 

The  call  handler  reported  that  the  perceived  geographical  remoteness  of  the  patient,  alongside  a 
personal sensitivity to the situation, contributed to the decision not to pursue direct contact with Ms 
Thornton. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Following  receipt  of  your  report,  the  Ambulance  Service  has  undertaken  a  comprehensive  review  of 
current procedures, training, and guidance provided to call handlers. The Trust has taken the following 
actions: 

1. Review of Call Handling Guidance 

Following a letter from Professor Jonathan Benger in April 2021 regarding clinical validation processes, 
the  Association  of  Ambulance  Chief  Executives  established  a  clinical  validation  process  in  October 
2023 for patients threatening suicide, which has been adopted by the Isle of Wight Ambulance Service. 

Calls of this nature are triaged as either Category 3 under NHS Pathways or Category 5 “Hear and Treat” 
calls.  The  Computer-Aided  Dispatch  (CAD)  system  highlights  patients  who  have  deliberately  or 
accidentally taken an overdose or where there is a potential threat of suicide. If no clinical validation 
has  taken  place  within  30  minutes,  the  system  automatically  upgrades  the  incident  to  a Category 2 
response. This functionality has been in place within the Trust since 2023. 

At  present,  there  is  no  NHS  Pathways  outcome  that  results  in  a  Category  1  response  for  a  patient 
threatening to hang themselves, even where means are present. A Category 1 response is only triggered 
where a patient is actively in the process of hanging. 

Patients  expressing  suicidal  ideation  and  access  to  means  (excluding  ingestion  or  overdose)  are 
escalated  to  the  duty  Operational  Commander  within  the  control  room  for  further  risk  assessment, 
including liaison with the police control room for additional support and intervention. 

This incident and your Prevention of Future Deaths report will be formally reported to the national NHS 
Pathways  group.  It  has  also  been  raised  at  the  National  Heads  of  Emergency  Operations  Centre 
meeting,  with  a  request  that  existing  pathways  be  reviewed  to  consider  whether  a  Category  1 
disposition is appropriate in such circumstances. 

Completion date: January 2026 

3.  Training and Reinforcement of Processes for Suicidal Patients and Remote Callers 

Additional training has been introduced for all call handlers to reinforce the appropriate management 
of calls involving suicidal patients. 

This includes: 

  Reinforcement of escalation pathways where risk is identified 
  Clarification of response categories and associated decision-making 
  Emphasis on proactive information gathering and risk assessment 

Training is being delivered through mandatory refresher sessions and updated training materials. 

Implementation period: February to April 2026 

4.  Clarification of Procedures for Contacting the Individual at Risk 

Guidance  has  been  amended  and  strengthened  to  make  clear  that  where  relevant  information  is 
incomplete, call handlers must make reasonable attempts to contact the individual directly, wherever 
they are located, in order to obtain information necessary for an accurate risk assessment. 

The revised guidance explicitly confirms that: 

 

The physical location of the call handler is not a barrier to contacting the individual by telephone 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   Call handlers are expected to pursue direct contact wherever appropriate 

In addition, clear direction has been issued to the call handling team regarding escalation procedures 
where a call handler feels unable to manage a call due to personal sensitivity or other factors. In such 
circumstances, the call must be escalated immediately to a senior colleague so that another member 
of the team can take over and ensure there is no delay in the patient pathway. 

Completion date: January 2026 

The Trust remains fully committed to learning from this incident and to strengthening its systems and 
processes to reduce the risk of similar occurrences in the future. We will continue to work with national 
bodies  to  ensure  that  guidance  and  NHS  Pathways  appropriately  reflect  the  risks  associated  with 
suicidal patients, including those involving potential hanging. 

I hope that the contents of this letter provide appropriate assurance that the concerns raised have been 
carefully considered and addressed. 

Yours sincerely, 

Chief Executive Officer 
IWT & PHU