Sunny Eymond

Date of report	6 May 2026
Reference	2026-0246
Deceased	Sunny Eymond
Coroner	Simon Burge
Coroner area	Hampshire, Portsmouth Southampton
Organisation named	Avon and Wiltshire Mental Health Partnership NHS Trust
Source	judiciary.uk record
Responses published	1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS
2013

Please do not include any living persons’ names in this document, in
accordance with the Chief Coroner’s PFD Publication Policy (2026).

1.

2.

3.

CORONER
I am Simon BURGE, HM Assistant Coroner, for the coroner area of
Hampshire, Portsmouth and Southampton.

DATE OF REPORT
06 May 2026

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.

4.

THIS REPORT IS BEING SENT TO

1. NHS England (PFDs/Reg28)
2. Chief Coroner - PFD Reports

You are under a duty to respond to this report within 56 days of the date of this
report, namely by June 28, 2026. I, the coroner, may extend the period if an
appropriate application is made.

5.

YOUR RESPONSE
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.

I have a duty to send a copy of your response to the Chief Coroner.

In accordance with the Chief Coroner’s Publication Policy, you should send
me any representations regarding publication of your response. These
representations should be made at the same time as the response is provided.
I will pass any representations received to the Chief Coroner for a decision.

Please note any links to webpages included in the response will not be
checked for sensitive information prior to publication, as the information is
already online.

The names of those who do not respond to PFD reports are regularly
published on the Chief Coroner’s webpages Non-responses to Prevention of
Future Death (PFD) reports - Courts and Tribunals Judiciary.

6.

SUMMARY OF CORONER’S CONCERN

 a) the lack of guidance at a national level concerning the transfer of
patients with both serious eating disorders and complex emotional
needs from one trust to another eg when they leave home to go to
university in another part of the country and
b) the lack of a clear treatment pathway/protocol for such individuals.'

7.

ACTION SHOULD BE TAKEN
In my opinion unless action is taken to address the above concerns then there
is a significant risk of future deaths and I believe each of you have the power
to take such action.

8.

INVESTIGATION AND INQUEST

On 29 May 2024 I commenced an investigation into the death of Sunny Elise
EYMOND aged 23. The investigation concluded at the end of the inquest on
01 May 2026. The conclusion of the inquest was that: Narrative

9.

CIRCUMSTANCES OF DEATH

Firstly, the jury would like to offer their sincere condolences to the family.

It is clear from the evidence and not in dispute that Sunny died at Winchester
Hospice,
Romsey Road, Winchester, Hampshire on 27th May 2024. Sunny had been
suffering from Anorexia Nervosa together with a personality disorder and
complex Post Traumatic Stress Disorder for many years, having spent lengthy
periods of time in and out of hospital, whilst detained under Section 3 of the
Mental Health Act and being subjected to forced feeding by nasogastric tube.
Her first episodes of nasogastric tube feeding started in October 2020 at the
Royal Hampshire County Hospital for anorexia nervosa before being
transferred to The Priory where she was detained under the Mental Health Act
under section 3. During this time spent at Skylark ward Sunny was fed via
nasogastric tubing under restraint, which we believe contributed to the start of
her complex PTSD. Sunny did however, make progress in terms of weight
gain. During this period, Sunny’s diagnosis was changed from anorexia
nervosa to EUPD and eating disorder and then 6 months later, anorexia
nervosa was removed and EUPD was the formal diagnosis. We find that whilst
this may have been helpful for Sunny and her family for her treatment and
care, we recognise that this had an impact on further treatment pathways
when being discharged (and in future interventions). It is noted that Sunny
took an overdose of paracetamol in September 2021 prior to her discharge in
October 2021 at this point she was no longer sectioned under the mental
health act. In 2022 Sunny was detained under section 2 of the mental health
act and admitted to Royal Hampshire County hospital and subsequently
transferred to ICU on two separate occasions for life saving treatment which
included chemical restraint. From the professional evidence we heard this
would have had a traumatic effect on Sunny going forward along with ongoing
continuous force-feeding in hospital. Sunny was transferred from hospital and
a bespoke ward at Parklands hospital was created for her. Whilst at Willow

 ward, Sunny made significant progress despite ongoing challenges and was
able to receive 100% nutrition orally by September 2023. We recognise that it
was important for Sunny to set and achieve a goal of attending Bristol
University, and we acknowledge that the healthcare providers involved worked
hard to achieve that goal. After Bristol’s fit to study panel, they accepted her.
Sunny was able to complete the first term at university however her weight
dropped and had to spend an extended period of time at home after
Christmas. Following Sunny’s overdose on the 23rd April 2024 she was
admitted to BRI for emergency treatment in ICU. Sunny made a good physical
recovery from this. Sunny was then transferred to the hospice for symptom
treating care on the 10th May 2024 . Following the exploration of options in the
professional meeting on the 16th May, all professionals were in agreement
that the end of life trajectory was the correct pathway and she sadly passed
away on the 27th May 2024.

a) There were multiple referral processes, being carried out simultaneously,
and the process took several months. We do not consider these delays to
have had any significant causative effects in relation to her death.

b) We consider that there were multiple failings in communication and sharing
of information between members of Southern Health Trust and AWP e.g.
failure to share tribunal records from Southern Health, multiple emails
reportedly sent/not received or read). However, we consider that this did not
contribute more than minimally, negligibly or trivially to Sunny’s death.

c) We acknowledge healthcare professionals in both Hampshire and Bristol
made great efforts to try and find a sensible solution for joint working. This was
difficult because of the different corporate and functional structures in place in
Hampshire and Bristol. The unique complexity of this case added to the
difficulties faced by all involved.

d) Whilst understanding that this was a complex and extremely challenging
handover of care, we do agree that there were some joint failings in relation to
the care package particularly around the lack of community mental health
provision and Sunny’s understanding of where this would come from over time
and how it would be continued. We agree that a robust care package was not
established prior to the transfer of care due to the uniqueness of the case, for
example, Bristol making it evident that they were unable to replicate the
bespoke care package which was established at Parklands for Sunny.

e) We find that there were no grounds for delaying the transfer of care,
although we recognise that following the formal handover meeting on the 15th
April, there was uncertainty who would be providing Sunny with psychological
support.

f) There was a failure in the overall oversight of the transfer of care as there is
no evidence that this was escalated to Trust senior management in Bristol. If
senior management had been engaged, this could have provided support for
the patient facing unit and might have accelerated the assembly of a complete
care package; including the appointment of a care-coordinator or equivalent.

 Due to the issues with the referral process, there should have also been an
escalation to Trust senior management in Hampshire to aid effective
communication going forward in the transfer of care. This also includes the
complications of navigating the legal framework.

g) There was a failure that Sunny was left from 17th April until 29th April
without any planned 1:1 sessions with a professional. This failure arose
because of the points we discuss below.

h) Whilst we acknowledge that risks were discussed at the transfer of care
meeting there was no suitable risk management plan established. This was
particularly relevant for the period of time immediately after the transfer when
Sunny was left without appropriate professional support.
Having considered all the evidence concerning the transfer of care between
Hampshire and Bristol services, we have identified some systemic and
communication failings. We do not, however, consider the cumulative effect of
these identified failings contributed more than minimally, negligibly or trivially
to Sunny’s death. Sunny’s death was due to an irreversible illness affecting
Sunny’s cognition and causing profound weight loss.

10. CORONER’S CONCERNS

During the course of the inquest I heard evidence 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:

1. While the two trusts involved in the inquest (Southern Health and Avon &
Wiltshire Mental Health Partnership NHS Trust) have undertaken reviews,
learned lessons and implemented changes following Sunny's death, the same
has not happened at a national level/England wide Trust level.
2. Firstly, I am concerned that a risk of death may arise in the future if the
concerns raised are not addressed more widely and brought to the attention of
other Trusts and consideration is not given to the production of national
guidance on cross Trust transfer of complex cases, particularly those involving
patients with a diagnosis of an eating disorder and complex Post Traumatic
Stress Disorder/Emotionally Unstable Personality Disorder/complex emotional
needs.
3. Secondly, I am concerned that there is a gap at a national level (identified
by both SH and AWP) in terms of a pathway for those with a diagnosis of both
an eating disorder and complex emotional needs. This lack of a pathway
created difficulties when Sunny was transferred from SH (Hampshire) to AWP
(Bristol) in order to attend university. It meant that there was an inability to
appropriately 'map' her treatment needs to the available mental health
services in Bristol. I believe that this needs to be addressed at a national level
and not just left for each Trust in England. It is a real concern, given the very
high risk of death associated with those with both Anorexia Nervosa and a
personality disorder, as was the case here.
4. There is currently no national guidance on how best to manage and plan for
Trust to Trust transfers of highly complex cases (in particular those involving
patients with both a diagnosed eating disorder such as AN and complex

 emotional needs). Guidance is therefore required as to the need for:
a) Senior management oversight of the transfer
b) Risk assessments at the time of transfer
c) Clear escalation procedures if concerns are raised during the transfer and
d) Training on any such national guidance
5. There is currently no national specified treatment pathway for individuals
who present with co-existing eating difficulties and complex emotional needs.
This, in turn, impacts how services are commissioned, as commissioning
arrangements are largely organised around set, diagnosis-specific pathways.
To ensure patient safety and national consistency, there is a need for national
guidance addressing:
a) How to develop a pathway/protocol for patients with eating disorders and
complex emotional needs
b) When bespoke services (such as the creation of Willow Ward at Parklands
Hospital in Sunny's case) are required
c) How patients with overlapping needs should be assessed and managed
using a formulation-led approach, where single- diagnosis pathways are not
appropriate

11. COPIES AND PUBLICATION OF THIS REPORT

I have a duty to send a copy of my report to every Interested Person who in
my opinion should receive it.

I also may send a copy of the report to any other person who I believe may
find it useful or of interest.

I can confirm I have sent the report to:
[please do not use individual’s names, but instead roles/titles]

 Treating Clinician (KB)
 Broadmead Medical Bristol
 Avon and Wiltshire Mental Health Partnership NHS Trust
 Hampshire Hospitals Foundation Trust (HHFT)
 Southern Health Foundation Trust (now HIOWH)
 Bristol University Wellbeing Department
 Parents
 University Hospitals Bristol & Weston
 Hampshire County Council
 Chief Coroner - PFD Reports

I also have a duty to send a copy of the report to the Chief Coroner.

You may make representations to me, the coroner, about the publication of the
contents of this report in line with Chief Coroner’s PFD Publication Policy
(2026). Any representations will be sent to the Chief Coroner alongside the
report. Please refer to box 4 above for additional information relating to the
publication of reports and responses.

 12. SIGNATURE

Simon BURGE
HM Assistant Coroner for
Hampshire, Portsmouth and Southampton

Responses

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.

Response from NHS England

Mr Simon Burge
HM Assistant Coroner
for Hampshire, Portsmouth
and Southampton
Coroner’s Office
Castle Hill
Winchester
Hampshire
SO23 8UL

Dear Mr Burge,

National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG

8 June 2026

Re: Regulation 28 Report to Prevent Future Deaths – Sunny Elise Eymond who
died on 27th May 2024.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 6th May
2026 concerning the death of Sunny Elise Eymond on 27th May 2024. In advance of
responding to the specific concerns raised in your Report, I would like to express my
deep condolences to Sunny’s family and loved ones. NHS England is keen to assure
the family and yourself that the concerns raised about Sunny’s care have been listened
to and reflected upon.

Your Report raises the following concerns:

1. There is a lack of national guidance concerning the transfer of patients with
both serious eating disorders and complex emotional needs from one trust to
another. Your report notes there also ought to be national guidance addressing
when bespoke services are required, and how patients with overlapping needs
should be assessed and managed when single-diagnosis pathways are not
appropriate.

2. There is a lack of a clear treatment pathway/protocol for such individuals.

NHS England expects to publish the Mental Health Personalised Care Framework
shortly. The Mental Health Personalised Care Framework sets out the approach and
related principles and actions for delivering personalised care for adults and older
people with severe mental health problems. The framework includes a section on
expectations for any transfer of care between services including the following:

• What works best for the person in terms of engagement and their

preferences around care.

• Personal relapse indicators: how these manifest, what does and does not
work for the person in preventing relapse at different stages of becoming
unwell, what harms could occur when they relapse.

• How the person can rapidly regain access to higher intensity services when
needed following a step down in care – including through self-directed

referral when appropriate. Access routes should reflect what is known about
the person’s illness and relapse indicators. Where significant time has
passed or the presenting problems are different, it may be appropriate to
include re-referral through primary care.

• Any current medication prescribed by the transferring team: indication,
monitoring requirements, expected duration of treatment and arrangements
that should be made if the person wishes their medication to be changed or
reviewed.

In January 2026, NHS England published National Guidance for eating disorder
services for children and young people. The guidance highlights that Children and
Young People Eating Disorder Services (CEDS) are integral to the integrated care
pathway. The guidance states it is important that all care pathways are locally co-
produced with stakeholders, including Children and Young People and their families,
and that they are also involved in care planning with other key stakeholders, as this
ensures optimal pathway integration and delivery of evidence-based, outcomes-
focused care.

In cases where Children and Young People present with a primary diagnosis of a
mental health condition, and have co-occurring problems with eating, the care of that
child or young person will typically be managed by Children and Young People Mental
Health team with input and support provided by CEDS. In this instance, CEDS are
expected to ensure effective support of the eating concerns whilst the Children and
Young People Mental Health team address the primary diagnosis. This may include,
but is not limited to, providing:

•

•
•

Shared care in partnership with Children and Young People Mental
Health team as the primary treating team
Consultation and clinical supervision
Training and supervising of the wider workforce

Generally, consideration should be given to prioritisation of interventions based on the
level of risk. Where the impact of the eating disturbance is high, eating disorder
treatment will usually be required initially, alongside support to avoid exacerbation of
the co-occurring condition.

The guidance recognises that many young people may be in their first treatment
episode when they reach 18 or transition to Community Adult Eating Disorder Services
(CEDS-AEDS), therefore it is important for services to take an individualised, flexible
approach to transition if treatment is incomplete. Some of the principles for managing
transition are:

• Comprehensive and timely planning: multi-agency/disciplinary planning in a
timely manner that allows treatment to be provided without delay. Clear
planning will include arrangements such as transfer of clinical records,
medication management, physical and psychological interventions and any
other care needs.

• Clear protocols and pathways for patients transitioning. Children and Young
People and their families, as well as clinicians and managers, should be
consulted during the development and evolution of such protocols.

• An agreed and well-structured, patient-centred transition care plan, focused on

the child or young person rather than on organisational considerations.

• Transition coordinators – often services appoint these roles to support the
transition between Children and Young People and adult mental health
services. These roles may involve the identification of a key worker from each
service or a permanent joint post shared between services. The role of the
transition coordinator is to guide and support young people and carers through
the transition process and function as a point of contact.

In 2019 NHSE published guidance for commissioners and providers on Adult Eating
Disorders. The guidance highlights the importance of joint working across services, it
states that coordinated care and good communication across services is essential to
ensuring that people with an eating disorder receive the care they need, to ensure
clear access and referral pathways so that all services can work together to prevent
gaps in provision and deliver the right care for the person.

Integrated care arrangements across services are essential and should:

• Set clear parameters around working relationships, including protocols
regarding referrals, assessments, access to treatments, and possible inpatient
admissions or intensive care.

• Use joint or interoperable record systems (digital records) where possible.
•

include regular liaison and joint working meetings, including coordinated review
meetings, joint training and education opportunities.

• Be based on a care plan that is co-produced (developed and written with a

person and their family, partner or carers).

• Have clearly established processes for when someone is not ready to engage

or refuses treatment.

The guidance also highlights that managing effective transitions is critical to ensuring
good quality care and it highlights that young people moving away from home or
attending university/college are particularly vulnerable. Principles for managing these
transitions are stated in the guidance:

• Transition protocols should be in place to ensure good communication between
services to avoid inconsistent messages or management approaches. This
should be based on a transition plan that includes risk assessment and
monitoring, and an agreed next appointment with the CED team or with the
person’s allocated care coordinator.

• For geographical transitions, CED services should work closely with primary
care providers, CED services in other areas and university mental health
services to remove gaps in care and delays in treatment that tend to occur when
a person moves to a new area and needs to register with a new GP. Transitions
should be seamless, with no gaps in support or quality of provision. People
should be seen by the new CED service without delay.

In addition, the guidance highlights the person’s level of need may require input from
multiple services at the same time. An integrated rather than sequential approach
should be taken, with careful thought given to which service should be the lead in this
process to ensure continuity of care. Having a comorbid condition should not be a
reason for delaying or rejecting someone for treatment.

Regional Response

NHS England’s South East Regional Team have liaised with the Integrated Care
Board (ICB) about this Report. It is noted that the two NHS Trusts involved in the
inquest have already undertaken reviews, learned lessons, and implemented changes
following Sunny’s death. From a regional perspective there is learning for the oversight
of NHS commissioned services, particularly where complex patients move across
different services and geographical boundaries. As a region we will take this learning
to our respective contract quality review meetings with our Lead Providers to ensure
that there is adequate assurance of improvement being embedded and sustained to
ensure such a tragedy does not happen again.

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
Sunny, 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

The report

Responses

Related reports

Other reports by Simon Burge

Track Avon and Wiltshire Mental Health Partnership NHS Trust