Source · Prevention of Future Deaths

Abigail Jelley

Ref: 2025-0509 Date: 13 Oct 2025 Coroner: Nicholas Walker Area: Hampshire, Portsmouth and Southampton Responses identified: 1 / 1 View PDF

Community Mental Health Teams lack mandatory perinatal red flag training and professional curiosity, exacerbated by cultural issues and structural leadership problems, risking inappropriate care for vulnerable mothers.

Date 13 Oct 2025

56-day deadline 8 Dec 2025 est.

Responses identified 1 of 1

Community health care and emergency services related deaths Mental Health related deaths Suicide (from 2015)

Coroner's concerns

AI summary

View full coroner's concerns

Community Mental Health Teams do not receive mandatory training on the perinatal red flags that are used when assessing patients with postnatal mental health issues. The team concerned with Abigail did request training but, a year after Abigail’s death, they had not received it. They were told that an assessment had been made by those senior to them that such training is not mandatory. That women suffer poor mental health before and after giving birth is sadly common and I am concerned that there is a risk of future deaths and that a large and vulnerable group of patients will not receive appropriate care. The Perinatal Team are expert in assisting patients such as Abigail. However, they are not commissioned to complete urgent visits and must refer patients to the community mental health teams who lack the specialist training and who are likely, due to the reasons outlined above, unaware of the perinatal red flags. I am concerned that women in need will not receive the appropriate mental health care and that there is a risk of future deaths. Abigail was known to the community mental health services for just a few weeks. She had been living with her parents immediately before she died and they had attended medical appointments with her. Abigail’s parents were not spoken to by mental health professionals about their daughter’s circumstances when they would have been able to provide valuable information about her research into and planning around ending her life. It was accepted that there was a lack of professional curiosity shown by professionals both in Abigail’s case and generally and I am concerned that there is a risk of future deaths. It was accepted that there were cultural issues within the trust services. A report into Abigail’s death concluded that these included ‘a lack of professional curiosity, lack of escalations of deteriorating patients, non-patient centred decision making and a linear approach to risk assessment and formulation.’ I am concerned that there are structural issues with the leadership of the Hampshire and Isle of Wight Healthcare Trust that is to the detriment of patients like Abigail, and I am concerned about the risk of future deaths.

Responses

1 respondent

Hampshire and Isle of Wight Healthcare NHS / Health Body

8 Dec 2025 PDF

Action Taken

The Trust is rolling out a redesigned training programme for assessing and managing all risk in mental health, and perinatal risks will be part of that programme. Multidisciplinary team (MDT) "huddle" meetings are now established and provide a forum for clinicians to discuss referrals and caseloads. (AI summary)

View full response

Dear Mr Walker

I write in response to the Regulation 28 Report issued following the inquest into the death of Abigail Jelley.

Firstly, I am sorry for the shortcomings in the support provided by the Trust for this young woman. The Trust’s Internal Review Report and the findings from the Inquest demonstrate that the Trust’s organisation and delivery of care was not as good as Abigail and her family had a right to expect.

As you state, the Perinatal Team are expert in assessing patients such as Abigail. However, they are not commissioned to complete urgent visits and must refer patients to the Community Mental Health Teams. This is an arrangement that is common in most parts of the country. The important issue is the drawing on specialist perinatal expertise when needed, through very close working between the Crisis Resolution Home Treatment Teams (CRHTs) and the specialist Perinatal Team.

The “Perinatal Red Flags” is information that is primarily targeted towards non-mental health professionals. It is not mandatory training for Mental Health Registrants, for whom it will have been an integral part of their core education in becoming a qualified mental health practitioner. What we are doing, however, is rolling out a redesigned training programme for assessing and managing all risk in mental health, and perinatal risks will be part of that programme.

Whilst there was some engagement with Abigail’s family, the Trust accepts that it was clearly insufficient.

There was also a lack of professional curiosity in working with Abigail, and this has been worked on with the teams involved.

Multidisciplinary team (MDT) “huddle” meetings are now established and provide a forum for clinicians to discuss referrals and caseloads. There are also weekly MDT reviews, in which Band 7 team leaders are more directly supporting staff in their focus on urgent face-to-face assessments. Additionally, more senior clinical leadership involvement has also been provided, and the teams are being supported to implement a comprehensive Quality Improvement Plan. These measures are aimed at addressing the structural issues that you describe.

2

We are committed to learning, particularly from tragedies such as Abigail’s death, and ensuring that everyone in our care receives the very best care and treatment possible.

If you require any further information, please do not hesitate to contact me.

Report sections

Investigation and inquest

On 13th November 2024 I commenced an investigation into the death of Abigail Eleanor Ann Jelley who was 34 when she died. The investigation concluded at the end of the inquest on 24th September 2025. The conclusion of the inquest was that Abigail died on 12th November 2024 at work premises below her home address in Waterlooville, Hampshire having intentionally harmed herself causing fatal blood loss. She intended by her act to end her life. The deceased was suffering with post-natal depression and in the weeks leading to her death she asked mental health professionals for help. It was established that there were failings in training, culture and knowledge by some of the professionals charged with Abigail’s care.

Circumstances of the death

Abigail was a 34-year-old mother of two who suffered a crisis in her life from the end of October 2024 until her death a few weeks later. The crisis arose out of post-natal depression following the birth of Abigail’s second child earlier in 2024. During this period she seen by different mental health professionals whose job it was to react to that crisis and attempt to assist her through it. A review into her death was critical of the care she received, and I heard evidence from those involved in the review. All teams concerned fall under the Hampshire and Isle of Wight Healthcare Trust.

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Shared signals

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Report details

Reference: 2025-0509
Date of report: 13 October 2025
Coroner: Nicholas Walker
Coroner area: Hampshire, Portsmouth and Southampton

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 8 Dec 2025 (estimated).

Sent to

Hampshire and Isle of Wight Healthcare

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.