Source · Prevention of Future Deaths

Samantha Young

Ref: 2025-0375 Date: 25 Jul 2025 Coroner: Henry Charles Area: Hampshire, Portsmouth and Southampton Responses identified: 2 / 2

A lack of training for staff, especially agency staff, in mental health risk assessments, and persistent failure to engage and communicate with patients' families, compromise patient safety.

Date 25 Jul 2025

56-day deadline 19 Sep 2025 est.

Responses identified 2 of 2

Mental Health related deaths Suicide (from 2015)

Coroner's concerns

AI summary

A lack of training for staff, especially agency staff, in mental health risk assessments, and persistent failure to engage and communicate with patients' families, compromise patient safety.

View full coroner's concerns

A. Assessment of the risk that a patient poses to themselves or others is clearly a cornerstone of the work of an NHS Trust dealing with mental health. At the material time there was a lack of any training as to compilation of risk assessments. I was informed by a senior manager of Hampshire and Isle of Wight Healthcare NHS Trust that with the translation of Southern Health NHS Foundation Trust into the new Hampshire and Isle of Wight Healthcare NHS Foundation Trust that issue of training is being addressed. However it emerged at the inquest that there do not appear to be any firm plans to train agency staff. Agency staff form a significant percentage of frontline staff. Hampshire and Isle of Wight Healthcare NHS Trust should review its provision of training for agency staff, in particular in respect of risk assessments. B. Wider family and friends of the deceased perspective were not contacted.. A patient's family and friends are clearly an invaluable resource for learning more about a patient's mental health and specifically risk to life, the support available to the patient and the potential for synergistic support with the NHS Trust. This PFD is not the first time that the issue has been raised with Southern Health NHS Foundation Trust: in 2023 the Senior Coroner for Hampshire, Portsmouth and Southampton issued a PFD on similar grounds arising out of the inquest into the death of Kirsty Taylor. The Senior Coroner observed in the PFD that "I remain concerned (as it is a matter I have raised on many occasions at inquest and again as a result of the experiences of the family in this case), that communication with the families of patients with mental health difficulties is still not being effectively achieved. Nor are such families being sufficiently, effectively and meaningfully listened to or understood when they voice concerns, based on their experience of the patient outside of a treatment or assessment environment. Consequently, I am concerned that such matters are not being reflected sufficiently or frequently enough in the onward treatment of those patients or in the clinical curiosity afforded to their conditions." Moreover, in 2021 a report commissioned by NHS England into Southern Health Foundation Trust similarly reported on shortfall in communication with families. Hampshire and Isle of Wight Healthcare NHS Trust should review guidelines and procedures concerning communication with family and friends of patients with mental health difficulties by its permanent and agency staff, and monitoring of whether such communication has taken place.

Responses

2 respondents

Hampshire and Isle of Wight Healthcare NHS Foundation Trust NHS Trust

17 Sep 2025 PDF

Action Taken

The Trust has updated its data insights visualisation platform to capture all essential data, improved its Triangle of Care initiative, and offers the Triangle of Care training and Esther coaching to agency colleagues. The Trust has embedded carer engagement across all teams, including those supported by long-term agency staff. (AI summary)

View full response

Dear Mr Charles

Please find enclosed the Trust’s response to the Regulation 28 report issued following the inquest into the death of Samantha Young. There has been considerable discussion of the issues you raised and the response has had input from a number of executive directors as well as senior clinical staff.

I trust our response helps you understand the steps we are taking to address these areas and that you will not hesitate to contact me should you have any further queries.

Department for Health and Social Care Central Government

16 Oct 2025 PDF

Action Planned

The Trust is considering ways to better support agency staff in risk management training, and commissioned an independent audit to review the adequacy of the Trust’s arrangements for involving families and carers. (AI summary)

View full response

Dear Mr Charles

Thank you for your Regulation 28 report to prevent future deaths dated 25 July 2025 about the death of Samantha Kate Young. I am replying as the Minister with responsibility for mental health.

Firstly, I would like to say how saddened I was to read of the circumstances of Samantha’s death, and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.

I have noted the contents of your report, and the matters of concern raised relating to the local provision of risk assessment training for agency staff and guidelines and procedures around communications with family and friends of patients with mental health difficulties. In responding, I have liaised with NHS England and Hampshire and Isle of Wight Healthcare NHS Foundation Trust.

I have been informed by the Trust that the position in respect of agency staff and training is a complex one as agency nurses are employed by their agencies and typically do not have access to the in-house training programmes of the NHS Trusts they work at, for a number of logistical and financial reasons. However, given the specific focus on risk management arising from this case and more generally, the Trust is considering ways in which it can better support agency staff to develop in this area.

In recognition of the importance of engagement with families and carers, the Trust last year commissioned an independent audit of this area. Specifically, the purpose of the audit was to review the adequacy of the Trust’s arrangements for involving and listening to families and carers so that the Trust learns from their feedback and experiences. The findings of the audit underline the Trust’s commitment to ensuring

that patients’ families feel heard, respected, and involved in the care of their loved ones. The findings also outline the programmes of work that are in place as the Trust seeks to embed a culture of compassionate, inclusive care across all of its services, which include improved collaboration with partners and other organisations; improvements to its Triangle of Care initiative; and upskilling staff coaches supporting the development of colleagues to create a culture of continuous improvement and ensure person-centred care.

I understand that more detailed information about these issues, along with the key findings of the Trust’s independent audit, has been provided by the Trust in its response to your report.

I hope this response is helpful. Thank you for bringing these concerns to my attention.

Report sections

Investigation and inquest

On 28 November 2023 I commenced an investigation into the death of Samantha Kate YOUNG aged 49. The inquest was concluded on 5th June 2025. The medical cause of death was 1a Hanging.

Circumstances of the death

A narrative conclusion was recorded at Box 4 of the Record of Inquest On 20th November 2023 Samantha Young died at her home, . Sadly, she had intentionally taken her own life by hanging herself with a ligature. The background is that Samantha Young had struggled for a number of years with her mental health. She had, impressively, managed to control an alcohol addiction and had indeed stopped taking alcohol. At the time of her death she was under very great stress following marriage breakdown and relocation. She had attempted suicide before. She was under the care of the CMHT, she had been and continued to access private medical care, which was undoubtedly beneficial. She had received substantial and effective family support. Her condition had deteriorated in early November 2023. It is clear that she had made many attempts – successfully so - to access medical treatment, and statutory service support right to the end whilst battling her mental health issues. She had done all she could to help herself and remain in the life of her daughter.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2025-0375
Date of report: 25 July 2025
Coroner: Henry Charles
Coroner area: Hampshire, Portsmouth and Southampton

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 19 Sep 2025 (estimated).

Sent to

Department of Health and Social Care

Hampshire and Isle of Wight Healthcare Foundation NHS Trust

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