Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0185, written 26 Mar 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Mar 2026 |
|---|---|
| Reference | 2026-0185 |
| Deceased | Melanie Pinnell |
| Coroner | Daniel Sharpstone |
| Coroner area | Suffolk |
| Category | Suicide (from 2015) |
| Organisation named | Norfolk and Suffolk 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Unity Healthcare 2. Dr 1 CORONER I am Daniel SHARPSTONE, Assistant Coroner for the coroner area of Suffolk 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 3rd March 2026 I opened an Inquest into the death of Melanie Ruth Pinnell. She was 57. The Medical cause of death was given as: 1a) Hanging 2 Depression The conclusion was suicide contributed to on the balance of probabilities more than minimally by non-prescription of Sertraline 50mg once a day recommended by a psychiatrist approximately two months prior to her death, and absence of mental Health input following a mental health consultation approximately two months prior to her death. 4 CIRCUMSTANCES OF THE DEATH Melanie had a history of depression from at least 2004 Her mental health had recently deteriorated secondary to several social stressors She had a Consultation with a GP on 10/2/25 stating that: ‘Every so often she takes an 'emotional dive' can't stop crying, becomes paranoid that people are talking about her, feels suicidal. Has a couple of times had urges to act on her suicidal ideation. Struggles with anxiety all the time, low levels sensation of a knot in her stomach all the time.’ Melanie had a Consultation with a Primary Care Network (PCN) Mental Health Worker on 20/2/25: She described ‘feeling extremely low, feelings of despair, suicidal thoughts’ This Consultation was referred to the GP. No action was taken by the GP practice The PCN worker spoke to a Consultant Psychiatrist on 26/2/25 who recommended starting Sertraline 50mg once a day. The PCN Mental Health Worker tasked the GP to relay this to the patient. This was never carried out by the GP. Regulation 28 – After Inquest Document Template Updated 30/07/2021 There was no follow up arranged at the GP practice following these consultations until her death on 4th May 2025 when she was found hanging at home. She had left a final note. 5 CORONER’S CONCERNS During the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In these circumstances it is my statutory duty to report to you: MATTERS OF CONCERN No follow-up was offered to Melanie by the GP practice after February 2025 despite Melanie describing suicidal ideation and suicidal thoughts The request for Sertraline 50mg once a day given by a Consultant Psychiatrist to the Primary Care Network Mental Health Care Worker was not actioned by a GP working for Unity Healthcare Both pose a significant risk to patient safety. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths as detailed above, and I believe you or your organisation have the power to take any such action you identify. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by May 15, 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: 1. 2. Melanie Pinell’s next of kin NSFT I am 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. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Dated: 26/03/2026 Daniel SHARPSTONE Regulation 28 – After Inquest Document Template Updated 30/07/2021 Assistant Coroner for Suffolk 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.
Suffolk GP Federation CIC
Riverside Clinic, 2 Landseer Road, Ipswich, IP3 0AZ
Response to Report to Prevent Future Deaths
THIS RESPONSE IS BEING SENT TO: Daniel SHARPSTONE, Assistant Coroner for the
coroner area of Suffolk.
1. Respondent
Clinical Director, Unity Healthcare. In line with our duty under
Regulation 29 of the Coroners (Investigations) Regulations 2013, Unity Healthcare
provides this response to the Report to Prevent Future Deaths.
2. Date of response
Wednesday 13th May 2026
3. Confirmation of coroner’s matters of concern
Unity Healthcare formally acknowledges the two matters of concern raised following
the inquest into the death of Melanie Ruth Pinnell:
▪ No follow-up was offered to Melanie by the GP practice after February 2025
despite Melanie describing suicidal ideation and suicidal thoughts.
▪
The request for Sertraline
once a day given by a Consultant Psychiatrist
to the Primary Care Network Mental Health Care Worker was not actioned by a
GP working for Unity Healthcare.
4.
Investigation and reflection
Unity Healthcare wishes to express its deepest sympathies to the family and friends of
Melanie Pinnell.
Following this incident, we commissioned a comprehensive Patient Safety Incident
Investigation (PSII) in accordance with the NHS Patient Safety Incident Response
Framework (PSIRF). The investigation utilised system-based analytical tools, including
the Systems Engineering Initiative for Patient Safety (SEIPS) and the Yorkshire
Suffolk GP Federation CIC
Registered in the UK. Registration number: 06183049
Registered address: Riverside Clinic, 2 Landseer Road, Ipswich, IP3 0AZ
Reg. No: 1-140317426
Suffolk GP Federation CIC
Riverside Clinic, 2 Landseer Road, Ipswich, IP3 0AZ
Tel: 0345 2413313 Email: info@suffolkfed.org.uk Web: www.suffolkfed.org.uk
Contributory Factors Framework (YCFF). We engaged openly with the Norfolk and
Suffolk Foundation Trust (NSFT) and the Primary Care Network (PCN) to fully
understand the systemic vulnerabilities that contributed to this outcome.
The investigation concluded that the incident arose from a combination of interacting
system factors rather than individual error. Specifically, the required protocol for
prescribing queries (the "pink internal query hub slot") was bypassed in favour of an
individual "task," making the clinical request invisible to the wider team. Furthermore,
complex organisational boundaries between the Practice, PCN, and the Norfolk and
Suffolk NHS Foundation Trust (NSFT) resulted in gaps in accountability for actioning
specialist advice and a lack of systematic safety-netting for vulnerable patients.
5. Details of action taken or proposed
Based on our PSII findings, we are implementing the following safety actions with
specific oversight and timelines:
Addressing Concern 1: Gaps in Follow-up and Safety-Netting
▪ Formal Caseload Reviews: We are introducing a formal caseload review
between the practice and the Mental Health team to review plans and safety-
net actions. This is owned by the PCN MH Service Lead and GP Clinical Lead
for mental health.
▪ Managing Uncontactable Patients: We are standardising the process for
managing uncontactable patients by developing and implementing a new
Standard Operating Procedure (SOP).
Addressing Concern 2: Un-actioned Prescription Requests and Task
Limitations
▪ Removing Task-Based Prescribing: We are removing the use of the task
system for prescribing requests entirely and developing an approved, formal
pathway SOP.
▪ System Recording: To ensure visibility, all specialist advice will be recorded in
both of our clinical systems, SystmOne and Lorenzo.
▪ Defining Ownership and Escalation: The PCN MH Clinical Lead and GP
Clinical Lead for mental health are defining and re-enforcing clear ownership
for prescribing actions and follow-up, as well as introducing a formal escalation
SOP for incomplete actions.
Suffolk GP Federation CIC
Registered in the UK. Registration number: 06183049
Registered address: Riverside Clinic, 2 Landseer Road, Ipswich, IP3 0AZ
Reg. No: 1-140317426
Suffolk GP Federation CIC
Riverside Clinic, 2 Landseer Road, Ipswich, IP3 0AZ
Tel: 0345 2413313 Email: info@suffolkfed.org.uk Web: www.suffolkfed.org.uk
Outstanding Task Review System: A review system for outstanding tasks—
specifically ensuring visibility of tasks assigned to locums, absent staff, or staff who
have left the organisation—was implemented by Clinical Services Management in June
2025.
6. Shared learning
To ensure wide-reaching impact, the findings and new SOPs will be presented
internally at Unity Healthcare clinical meetings. Furthermore, an anonymised
summary detailing the risks of task-based messaging for prescribing requests will be
shared with the Suffolk and North East Essex Integrated Care Board (ICB) Quality
Lead to promote shared learning across the wider system.
7. Statement of truth
I believe the facts stated in this response are true to the best of my knowledge and
belief.
Clinical Director, Unity Healthcare
Suffolk GP Federation CIC
Registered in the UK. Registration number: 06183049
Registered address: Riverside Clinic, 2 Landseer Road, Ipswich, IP3 0AZ
Reg. No: 1-140317426
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