Source · Prevention of Future Deaths

Moira Parker

Ref: 2026-0239 Date: 30 Mar 2026 Coroner: Bina Patel Area: Bedfordshire and Luton Responses identified: 1 / 1 View PDF

Staff lacked sufficient knowledge and training on when to make occupational health referrals, leading to a delay in a stress risk assessment and support for a worker with long-standing concerns.

Date 30 Mar 2026
56-day deadline 25 Jun 2026
Responses identified 1 of 1

Coroner's concerns

AI summary
Staff lacked sufficient knowledge and training on when to make occupational health referrals, leading to a delay in a stress risk assessment and support for a worker with long-standing concerns.
View full coroner's concerns
From the contents of the letters left by Moira and the evidence heard at the  inquest, Moira raised concerns over a protracted period of time from July 2022 to October 2024 and a referral was not made to occupational health which  would have triggered the use of the stress risk assessment and provided  support both for Moira and those within the management team at Unilever, I  am not satisfied staff have sufficient knowledge and training about the  circumstances in which an occupational health referral can be made and the  support that is available.

Responses

1 respondent
Unilever Plc
PDF
Received

No AI summary available.

Report sections

Investigation and inquest
On 22 April 2025, I commenced an investigation into the death of Moira Diane Parker, aged 54 years. This inquest was concluded on the 18 March 2026.  

The medical cause of death was   1 a Fatal Haemorrhage and Haemothorax 1 b Stab Wounds to Neck and Wrist  How, when and where 

On 11 April 2025 Moira was found at Priory Marina River Bank, Barkers Lane, Bedford with stab wounds that were self-inflicted in the neck and wrist.   

Conclusion    Suicide – The Deceased intentionally took her own life following a deterioration in her mental health after a decline in her cognitive function.
Circumstances of the death
The Deceased, a Microbiologist, had worked for Unilever for thirty-six years in  research and Development (“R&D”), which was a job she loved. She had  struggled with mental and physical health issues for several years, which  included a decline in her memory and cognitive function. These were being  investigated by her GP through scans and blood tests. She was placed on  Hormone Replacement Therapy to assist with her symptoms thought to be  linked with menopause and although she reported some initial improvement  when she commenced therapy, her underlying memory and brain function  issues continued to exist since October 2022. Subsequently, she found herself under increasing pressure at work. She raised issues about her workload and  an increase in her working hours that included weekends, during meetings with her line manager in December 2022, March 2023 and in October 2024  when she said she reported that was struggling to keep up with workload. A  marked change in her demeanour was noticed by management in January  2025 where she appeared withdrawn and anxious. On the 5 February 2025  she contacted her GP through an eConsult reporting an escalation of her  memory issues, panic attacks and feelings of being unable to cope, burnt out,  the following day she certified herself sick from work. Although she was open  about her health issues and work-related pressures, an occupational health  referral was not made by management until 14 February 2025, after she went  on sick leave. Following this, she had an appointment with her GP on the 20  February 2025 where she discussed her symptoms and there was an  exploration of possible physical and psychological causes. A subsequent CT  scan revealed no physical abnormalities, but her bloods identified low folate  and subclinical hypothyroidism and medication was prescribed. A referral was  also made to the Memory Assessment Service for further investigation for her  ongoing symptoms. She was under the care of the Memory Assessment  Service from the 12 March 2025 to the 27 March 2025, on the afternoon of the  11 April 2025 she was found at Priory Marina River Bank, Barkers Lane,  Bedford with stab wounds that were self-inflicted in the neck and wrist.  Emergency Services attended but her death was confirmed by paramedics at  13:40 hours. She had last been seen at 07:30 hours that morning when she  had left her home informing her husband, she was attending her GP surgery to collect a fit note for work. Notes were left.
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 you have the power to take  such action.
Copies sent to
I can confirm I have sent the report to: [please do not use individual’s names, but instead roles/titles]2. Unilever PLC3. Zello UK Limited (Occupational Health)

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Report details

Reference
2026-0239
Date of report
30 March 2026
Coroner
Bina Patel
Coroner area
Bedfordshire and Luton

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: 25 Jun 2026.

Sent to

Unilver Plc

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