Source · Prevention of Future Deaths
Victoria Taylor
Ref: 2025-0455
Date: 5 Sep 2025
Coroner: Catherine Cundy
Area: North Yorkshire and York
Responses identified: 0 / 1
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Secondary mental health services failed to offer appropriate trauma-informed treatment pathways or initiate a multi-agency approach for a patient with acknowledged childhood trauma and complex needs.
Date
5 Sep 2025
56-day deadline
31 Oct 2025 est.
Responses identified
0 of 1
Coroner's concerns
Secondary mental health services failed to offer appropriate trauma-informed treatment pathways or initiate a multi-agency approach for a patient with acknowledged childhood trauma and complex needs.
View full coroner's concerns
Ms Taylor was assessed on three separate occasions between mid-May 2024 and the end of August 2024 by members of the Crisis and Acute Hospitals Liaison Teams. Ms Taylor was clear during all three assessments that her episodes of binge drinking and impulsive acts of self harm were the result of unresolved childhood trauma. Despite that, secondary mental health services considered there was no role for them in offering support or a treatment pathway to her. The safety plans agreed following these assessments were therefore limited and offered Ms Taylor no additional support beyond that which she was already accessing through the Horizons service. The assessment documents contained no discussion of treatment pathways for addressing trauma which might be accessed through the Community Mental Health Team, and no indication that such pathways had been OFFICIAL offered to Ms Taylor and rejected by her. Instead, it was suggested at the second assessment that Ms Taylor may wish to refer herself to a named private psychotherapy service at some point in the future. There was no rationale included in the second assessment for naming this service, and no explanation of what it might provide or why this could not be offered on the NHS via the CMHT. When Ms Taylor indicated at her third assessment that she had left a message with this private provider and received no response from them, the third safety plan simply suggested she try again. Mental Health services were aware at the time of the second and third assessments that a number of agencies were involved with Ms Taylor, but no multi-agency meeting or approach was suggested or called by them to consider the most appropriate support for Ms Taylor.
Report sections
Investigation and inquest
On 23 October 2024 I commenced an investigation into the death of Victoria Anne TAYLOR aged 34. The investigation concluded at the end of the inquest on 03 September 2025. The conclusion of the inquest was that: On the 22nd of October 2024 the body of Victoria Anne Taylor was recovered from the River Derwent near Malton, North Yorkshire by an underwater search unit. She was pronounced deceased at the scene on the same date.
Circumstances of the death
Ms Taylor's mental health deteriorated significantly between May 2024 and her death, with an escalation in incidents of suicidal ideation, threatened and actual self harm, and episodes of binge drinking. Her suicidal ideation exhibited a preoccupation with going into the river, which she actually entered in July 2024 and from which she had to be extricated. Ms Taylor was reported missing from home on 1 October 2024. On 22 October 2024 her body was recovered from the River Derwent near Malton, North Yorkshire by an underwater search unit.
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Prevention of Future Death Reporting
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Report details
- Reference
- 2025-0455
- Date of report
- 5 September 2025
- Coroner
- Catherine Cundy
- Coroner area
- North Yorkshire and York
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 31 Oct 2025 (estimated).
Sent to
- Tees, Esk and Wear Valleys NHS Foundation Trust
Non-response list
The Chief Coroner has confirmed the following did not respond within the required period:
- Tees Esk & Wear Valley NHS Foundation Trust