Jacqueline Potter
PFD Report
All Responded
Ref: 2025-0200
All 5 responses received
· Deadline: 19 Jun 2025
Sent To
Response Status
Responses
5 of 5
56-Day Deadline
19 Jun 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
Part 1
(1) Anne was not sent home for her first overnight leave with any codified ‘Risk’ and ‘Safety Planning’ document. Whilst it was widely accepted in this case that Anne’s husband was well versed and knowledgeable about his wife’s risks and the measures that might be necessary to help keep her safe whilst she was at home, not all families are as involved in their loved one’s psychiatric care, despite the Trust following the Triangle of Care principles. Whilst families are not mental health practitioners and are not expected to adopt that role within the community there appears to be an opportunity to supply families with a short, codified document dealing with salient points of risks and safety planning when a patient goes for their first overnight leave since being detained. This may equip families with the knowledge to spot signs of declining mental presentation and/or risk and provide them with the knowledge and/or tools to take appropriate steps to assist in safeguarding their loved ones whilst they are in the community. This concern (and any action deemed appropriate by the recipients of this PFD) is not intended to override autonomy of the patient and their own ability/responsibility to keep themselves safe, but the concern centres around their being an opportunity to assist families in spotting early warning signs that ‘something is wrong’ and to seek help and intervention (if/when appropriate) to minimise the risk of a patient taking their own life whilst in the community.
(2) It transpired during the Inquest that if an in-patient (detained or voluntary) accesses the secure unit Wi-Fi there are no algorithms or ‘search detection features’ to prevent access to websites pertaining to self harm and so these can be readily accessed by a group who are already vulnerable due to their acute mental health presentation with some element of inherent risk of suicide. It was noted, quite rightly, by legal representatives that workplace organisations can block access to certain sites they deem it undesirable for their workforce to access (such as sites relating to gambling, sexually inappropriate content etc) which shows that it is possible to limit access to certain websites and content when using a Wi-Fi provider. By allowing an already vulnerable group to have unfettered access to websites dedicated to self harm creates a risk of further deaths.
Part 2
(3) I am (and remain, having previously issued a PFD in a similar vain on the 26th June 2024) concerned about the lack of ‘importance’ given to menopausal care available to women on the NHS; especially when compared to private sector meaning that women who are not fortunate enough to be able to access private clinics and facilities may not be able to access the services and expertise they need at a very crucial transitional phase in their lives. Menopause is not a lifestyle choice, it is an unavoidable part of a woman’s natural biological cycle. Without wishing to introduce sweeping generalisations, menopause is likely to affect 50% of the population at some point in their lives [according to Statistics Times, women made up 50.75% of the UK population in 2024].
I am concerned that:
(i) Certain elements of medicine and clinical practice training are compulsory but having heard evidence at the Inquest around mandatory and statutory training modules I learnt that this covers areas such as GDPR training and disposal of sharp objects such as syringes. I was surprised to learn that menopausal training is not mandatory in any area of clinical practice or specialism. I am concerned that there is no requirement to undertake essential compulsory menopausal training for those working in ‘relevant’ clinical practices such as Mental Health Practice, Obstetrics and Gynaecology and Oncology, or even general as a general GP.
(ii) I was told that the Trust has just one ‘menopause specialist’ (a GP) who covers the entire Trust operations. Not all GP surgeries have a menopause specialist practitioner (or access to one) despite a GP usually being the first port of call for women in the community when seeking primary care. Those GP Surgeries who do have a practitioner who acts as a ‘specialist’ is often a GP with a personal interest who has taken the initiative to go on courses and broaden their learning and understanding, rather than any mandatory requirement for a Surgery [or group with multiple surgeries] to have an available community ‘front-line’ specialist.
I was told that the Trust does not have an “expert” in this field and it would be difficult to have one as menopause isn’t a disease or an illness. Whilst I do not dispute that is it not a disease, menopause is a condition; it does have symptoms and it does have recognised presentations, yet there appears to be a failure to recognise this condition as having equal importance to other ailments or diagnoses.
I was told during a previous PFD Response relating to menopausal knowledge and care within the NHS that “It is important to ensure that women understand common symptoms such as anxiety, stress and depression which they might experience during the menopause and where and when to seek help. The NHS website has resources….” This emphasises my concerns entirely; the lack of importance given to menopausal symptoms. If someone has concerns about heart disease, a worrying lump, a broken bone etc they expect to be able to consult a medically qualified professional who has a knowledge and understanding of their condition or presentation and can diagnose and treat accordingly; not just [and I paraphrase] ‘have a look at a website to help’.
I appreciate that each and every woman will experience perimenopause and menopause differently, their individual experience is unique to them and this, to some degree, creates difficulties as a ‘one size fits all’ approach (which is perhaps achievable in other medical specialisms and disciplines) cannot be offered, but the lack of recognition of the importance of this condition remains a significant concern. I had previously been told (back in a 2024 PFD response) of a roll-out of specialist menopausal care and upskilling of GPs but there was little evidence during the inquest that this has happened/is happening and women continue to approach and navigate the menopause without the support of expert clinicians or practitioners who understand and can treat the symptoms they are experiencing.
(1) Anne was not sent home for her first overnight leave with any codified ‘Risk’ and ‘Safety Planning’ document. Whilst it was widely accepted in this case that Anne’s husband was well versed and knowledgeable about his wife’s risks and the measures that might be necessary to help keep her safe whilst she was at home, not all families are as involved in their loved one’s psychiatric care, despite the Trust following the Triangle of Care principles. Whilst families are not mental health practitioners and are not expected to adopt that role within the community there appears to be an opportunity to supply families with a short, codified document dealing with salient points of risks and safety planning when a patient goes for their first overnight leave since being detained. This may equip families with the knowledge to spot signs of declining mental presentation and/or risk and provide them with the knowledge and/or tools to take appropriate steps to assist in safeguarding their loved ones whilst they are in the community. This concern (and any action deemed appropriate by the recipients of this PFD) is not intended to override autonomy of the patient and their own ability/responsibility to keep themselves safe, but the concern centres around their being an opportunity to assist families in spotting early warning signs that ‘something is wrong’ and to seek help and intervention (if/when appropriate) to minimise the risk of a patient taking their own life whilst in the community.
(2) It transpired during the Inquest that if an in-patient (detained or voluntary) accesses the secure unit Wi-Fi there are no algorithms or ‘search detection features’ to prevent access to websites pertaining to self harm and so these can be readily accessed by a group who are already vulnerable due to their acute mental health presentation with some element of inherent risk of suicide. It was noted, quite rightly, by legal representatives that workplace organisations can block access to certain sites they deem it undesirable for their workforce to access (such as sites relating to gambling, sexually inappropriate content etc) which shows that it is possible to limit access to certain websites and content when using a Wi-Fi provider. By allowing an already vulnerable group to have unfettered access to websites dedicated to self harm creates a risk of further deaths.
Part 2
(3) I am (and remain, having previously issued a PFD in a similar vain on the 26th June 2024) concerned about the lack of ‘importance’ given to menopausal care available to women on the NHS; especially when compared to private sector meaning that women who are not fortunate enough to be able to access private clinics and facilities may not be able to access the services and expertise they need at a very crucial transitional phase in their lives. Menopause is not a lifestyle choice, it is an unavoidable part of a woman’s natural biological cycle. Without wishing to introduce sweeping generalisations, menopause is likely to affect 50% of the population at some point in their lives [according to Statistics Times, women made up 50.75% of the UK population in 2024].
I am concerned that:
(i) Certain elements of medicine and clinical practice training are compulsory but having heard evidence at the Inquest around mandatory and statutory training modules I learnt that this covers areas such as GDPR training and disposal of sharp objects such as syringes. I was surprised to learn that menopausal training is not mandatory in any area of clinical practice or specialism. I am concerned that there is no requirement to undertake essential compulsory menopausal training for those working in ‘relevant’ clinical practices such as Mental Health Practice, Obstetrics and Gynaecology and Oncology, or even general as a general GP.
(ii) I was told that the Trust has just one ‘menopause specialist’ (a GP) who covers the entire Trust operations. Not all GP surgeries have a menopause specialist practitioner (or access to one) despite a GP usually being the first port of call for women in the community when seeking primary care. Those GP Surgeries who do have a practitioner who acts as a ‘specialist’ is often a GP with a personal interest who has taken the initiative to go on courses and broaden their learning and understanding, rather than any mandatory requirement for a Surgery [or group with multiple surgeries] to have an available community ‘front-line’ specialist.
I was told that the Trust does not have an “expert” in this field and it would be difficult to have one as menopause isn’t a disease or an illness. Whilst I do not dispute that is it not a disease, menopause is a condition; it does have symptoms and it does have recognised presentations, yet there appears to be a failure to recognise this condition as having equal importance to other ailments or diagnoses.
I was told during a previous PFD Response relating to menopausal knowledge and care within the NHS that “It is important to ensure that women understand common symptoms such as anxiety, stress and depression which they might experience during the menopause and where and when to seek help. The NHS website has resources….” This emphasises my concerns entirely; the lack of importance given to menopausal symptoms. If someone has concerns about heart disease, a worrying lump, a broken bone etc they expect to be able to consult a medically qualified professional who has a knowledge and understanding of their condition or presentation and can diagnose and treat accordingly; not just [and I paraphrase] ‘have a look at a website to help’.
I appreciate that each and every woman will experience perimenopause and menopause differently, their individual experience is unique to them and this, to some degree, creates difficulties as a ‘one size fits all’ approach (which is perhaps achievable in other medical specialisms and disciplines) cannot be offered, but the lack of recognition of the importance of this condition remains a significant concern. I had previously been told (back in a 2024 PFD response) of a roll-out of specialist menopausal care and upskilling of GPs but there was little evidence during the inquest that this has happened/is happening and women continue to approach and navigate the menopause without the support of expert clinicians or practitioners who understand and can treat the symptoms they are experiencing.
Responses
NHS England has implemented several initiatives to improve menopause care, including launching a Women’s Health Strategy, appointing a National Menopause Clinical Champion, investing in women’s health hubs, and developing new e-learning modules and a Primary Care Menopause Training Programme.
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Dear Ms Marsh, Re: Regulation 28 Report to Prevent Future Deaths – Jacqueline Anne Potter who died on 5 December 2022.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 24 April 2025 concerning the death of Jacqueline Anne Potter (known as Anne) on 5 December
2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Anne’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Anne’s care have been listened to and reflected upon.
Your Report raises concerns around the importance of providing families with the tools and knowledge to assist in safeguarding loved ones with mental health illness when they are in the community, along with the perceived lack of importance given to menopausal care available to women on the NHS. This response focuses on the issue of menopausal care and the areas which are within NHS England’s remit.
Menopause and perimenopause are increasingly recognised as a time that can, but not always, cause considerable distress to a woman. We have seen a rapid increase in demand for menopause care in recent years, as a result of more media attention. Whilst women receive high quality NHS menopause care in many areas, it is also acknowledged that variation across services locally / regionally remains.
Many women who are experiencing menopause symptoms attend their GP for help and advice. Menopause care is part of the core curriculum for General Practice, which is the basis of training for all GPs in order to qualify. The GP curriculum: Clinical topic guides highlights menopause care as a requirement, which has more recently been updated to emphasise a changing landscape in the management of menopause, the need to be aware of the mental distress experienced by some women in this period, and being up to date on all evidence-based treatment options. Improving awareness of mental health symptoms during menopause will help GPs to consider this as one of the causes, and to provide appropriate advice and treatment options.
Practice nurses also have a significant role in menopause care and are often the first port of call for someone experiencing difficulties, or who may have the opportunity to proactively enquire about the menopause. In 2024, NHS England published specific National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
5 June 2025
Menopause Educational resources to enhance learning for practice nurses. As the demand for menopause care has risen in recent years, some GPs and practice nurses seek further qualifications in more specialist care such as the training programme offered by the British Menopause Society. Many GP practices will now have at least one member of staff who is able to offer more complex menopause care. Whilst this may not be available at every GP practice in England, in many practices, and increasingly, there is a lead person who is able to offer this.
There is often variation between GPs and practices in the level of complexity of care they are able to provide. Women’s Health Hubs were piloted in 2023/2024, seeking to reduce the variations in reproductive healthcare which women reported receiving. They provide the option for women to be referred to more specialist reproductive health care (including menopause care) if the GP needs further advice. Women’s Health Hubs have yet to achieve full coverage, but have the potential to fill the gap in care where this is more complex. NHS England is working closely with its regions and Integrated Care Boards (ICBs) to ensure that every woman can access good menopause care wherever they are in the country.
Working in a multidisciplinary team (MDT) alongside mental health practitioners, GPs and menopause specialists are an essential part of good menopause care and are a key element of a future neighbourhood model of care, which will help to ensure that a range of professionals are involved in the most complex cases.
A toolkit that supports local areas to provide menopause information events and group consultations is under development to improve access and also to provide a forum for learning for other healthcare professionals. NHS England is working on menopause workforce support packages for employees and employers and developing a range of tools to upskill, including two e-learning packages (Menopause Awareness – elearning for healthcare and Menopause and people professionals eLearning for healthcare), decision support tools and a self-care factsheet to empower women to understand and self-manage their perimenopause and menopause symptoms, and to point them towards further sources of credible information.
Whilst I acknowledge the Coroner’s comments regarding menopause resources and use of the NHS website, appreciating that online resources do not compare to patient consultations with a medically qualified professional, the menopause page on the NHS website has also recently been updated to include the most up-to-date, evidence- based information on menopause. This includes information about symptoms, where to seek treatment, lifestyle changes that may help with symptoms, and signposting to other helpful resources.
NHS England’s StatMand Reform programme is leading work to optimise, rationalise and redesign statutory and mandatory training during 2025/26 in partnership with the Department of Health and Social Care, Health Services Safety Investigations Body (HSSIB) and NHS Resolution. There are three levels of mandatory training:
1. Nationally mandated – typically associated with statutory obligations, largely summarised in the Core Skills Training Framework or in other policy. This includes training on subjects such as the General Data Protection Regulation (GDPR) and handling of sharp objects, amongst many other things. It is this
nationally mandated training that NHS England is currently reforming (as stated above).
2. Locally mandated – each employing organisation will determine what should be mandated to all or most of their staff to meet priorities and patient needs. This training varies between organisations, with some similarities.
3. Profession or role specific mandated – this is determined by the respective professions and royal colleges and will form part of standards for professional development and curriculum for future trainees.
The potential for menopause training to be mandated has been raised as part of the NHS England reform work, which is yet to conclude it’s work. It is likely that menopause training would most appropriately fit at a professional/role specific level and we expect to engage with profession leads and royal colleges in due course to consider this, alongside a number of similar topics, once the reform of the nationally mandated training has concluded.
In addition, the Technology Enhanced Learning (Workforce, Education and Training directorate (WTE)) team at NHS England manage and host training on the e-lfh hub and Learning Hub platforms. National WTE colleagues work directly with subject matter experts within professional bodies and the NHS to design, develop and deliver e-learning training sessions/modules. They also work within defined medical training curriculums, as defined by the professional bodies and NHS England, and design and develop relevant e-learning sessions.
Menopause related online training available at the time of Anne’s death in 2022 included training within the General Practice 2012 Curriculum (e-GP) programme. The e-GP Programme provides a programme of e-learning modules covering the Royal College of General Practitioners (RCGP) curriculum. The programme has been designed to:
1. Facilitate the delivery of the RCGP curriculum at national, local and individual learner levels.
2. Provide relevant, comprehensive and accessible learning content for GPs working in the UK.
3. Embody adult learning principles and support a blended approach to learning.
4. Support postgraduate doctors in training to become GPs.
5. Support GPs in Continual Professional Development (CPD) and revalidation.
The e-learning modules which are part of this programme include ‘What is the Menopause’, ‘Managing the Menopause’, ‘Hormone Replacement Therapy (HRT)’ and ‘Premature Menopause’.
Other menopause related online training includes:
• The Sexual and Reproductive Health (E-SRH) programme, developed in partnership with the Faculty of Sexual and Reproductive Healthcare (FSRH). The programme supports a range of healthcare professionals and compliments the redesigned FSRH Diploma (DFSRH) as well as other FSRH qualifications.
In recent years, the NHS England National Menopause programme has also launched a series of awareness sessions, including the ‘Menopause awareness’ and ‘Menopause and people professionals’ e-learning packages referenced earlier on in this response, as well as e-learning on ‘Menopause and occupational health’.
NHS England notes that some of the above training became available following Anne’s death, but hopes that this provides some reassurance to the Coroner and Anne’s family that additional resources have since been made available to healthcare practitioners and further improvements have been made to menopause care, training and resources.
Anne’s tragic death has highlighted important gaps in the care of women experiencing perimenopause or menopause and the potential for improvements. NHS England will continue to promote high quality and equitable coverage of menopause care for all.
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 Anne, 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.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 24 April 2025 concerning the death of Jacqueline Anne Potter (known as Anne) on 5 December
2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Anne’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Anne’s care have been listened to and reflected upon.
Your Report raises concerns around the importance of providing families with the tools and knowledge to assist in safeguarding loved ones with mental health illness when they are in the community, along with the perceived lack of importance given to menopausal care available to women on the NHS. This response focuses on the issue of menopausal care and the areas which are within NHS England’s remit.
Menopause and perimenopause are increasingly recognised as a time that can, but not always, cause considerable distress to a woman. We have seen a rapid increase in demand for menopause care in recent years, as a result of more media attention. Whilst women receive high quality NHS menopause care in many areas, it is also acknowledged that variation across services locally / regionally remains.
Many women who are experiencing menopause symptoms attend their GP for help and advice. Menopause care is part of the core curriculum for General Practice, which is the basis of training for all GPs in order to qualify. The GP curriculum: Clinical topic guides highlights menopause care as a requirement, which has more recently been updated to emphasise a changing landscape in the management of menopause, the need to be aware of the mental distress experienced by some women in this period, and being up to date on all evidence-based treatment options. Improving awareness of mental health symptoms during menopause will help GPs to consider this as one of the causes, and to provide appropriate advice and treatment options.
Practice nurses also have a significant role in menopause care and are often the first port of call for someone experiencing difficulties, or who may have the opportunity to proactively enquire about the menopause. In 2024, NHS England published specific National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
5 June 2025
Menopause Educational resources to enhance learning for practice nurses. As the demand for menopause care has risen in recent years, some GPs and practice nurses seek further qualifications in more specialist care such as the training programme offered by the British Menopause Society. Many GP practices will now have at least one member of staff who is able to offer more complex menopause care. Whilst this may not be available at every GP practice in England, in many practices, and increasingly, there is a lead person who is able to offer this.
There is often variation between GPs and practices in the level of complexity of care they are able to provide. Women’s Health Hubs were piloted in 2023/2024, seeking to reduce the variations in reproductive healthcare which women reported receiving. They provide the option for women to be referred to more specialist reproductive health care (including menopause care) if the GP needs further advice. Women’s Health Hubs have yet to achieve full coverage, but have the potential to fill the gap in care where this is more complex. NHS England is working closely with its regions and Integrated Care Boards (ICBs) to ensure that every woman can access good menopause care wherever they are in the country.
Working in a multidisciplinary team (MDT) alongside mental health practitioners, GPs and menopause specialists are an essential part of good menopause care and are a key element of a future neighbourhood model of care, which will help to ensure that a range of professionals are involved in the most complex cases.
A toolkit that supports local areas to provide menopause information events and group consultations is under development to improve access and also to provide a forum for learning for other healthcare professionals. NHS England is working on menopause workforce support packages for employees and employers and developing a range of tools to upskill, including two e-learning packages (Menopause Awareness – elearning for healthcare and Menopause and people professionals eLearning for healthcare), decision support tools and a self-care factsheet to empower women to understand and self-manage their perimenopause and menopause symptoms, and to point them towards further sources of credible information.
Whilst I acknowledge the Coroner’s comments regarding menopause resources and use of the NHS website, appreciating that online resources do not compare to patient consultations with a medically qualified professional, the menopause page on the NHS website has also recently been updated to include the most up-to-date, evidence- based information on menopause. This includes information about symptoms, where to seek treatment, lifestyle changes that may help with symptoms, and signposting to other helpful resources.
NHS England’s StatMand Reform programme is leading work to optimise, rationalise and redesign statutory and mandatory training during 2025/26 in partnership with the Department of Health and Social Care, Health Services Safety Investigations Body (HSSIB) and NHS Resolution. There are three levels of mandatory training:
1. Nationally mandated – typically associated with statutory obligations, largely summarised in the Core Skills Training Framework or in other policy. This includes training on subjects such as the General Data Protection Regulation (GDPR) and handling of sharp objects, amongst many other things. It is this
nationally mandated training that NHS England is currently reforming (as stated above).
2. Locally mandated – each employing organisation will determine what should be mandated to all or most of their staff to meet priorities and patient needs. This training varies between organisations, with some similarities.
3. Profession or role specific mandated – this is determined by the respective professions and royal colleges and will form part of standards for professional development and curriculum for future trainees.
The potential for menopause training to be mandated has been raised as part of the NHS England reform work, which is yet to conclude it’s work. It is likely that menopause training would most appropriately fit at a professional/role specific level and we expect to engage with profession leads and royal colleges in due course to consider this, alongside a number of similar topics, once the reform of the nationally mandated training has concluded.
In addition, the Technology Enhanced Learning (Workforce, Education and Training directorate (WTE)) team at NHS England manage and host training on the e-lfh hub and Learning Hub platforms. National WTE colleagues work directly with subject matter experts within professional bodies and the NHS to design, develop and deliver e-learning training sessions/modules. They also work within defined medical training curriculums, as defined by the professional bodies and NHS England, and design and develop relevant e-learning sessions.
Menopause related online training available at the time of Anne’s death in 2022 included training within the General Practice 2012 Curriculum (e-GP) programme. The e-GP Programme provides a programme of e-learning modules covering the Royal College of General Practitioners (RCGP) curriculum. The programme has been designed to:
1. Facilitate the delivery of the RCGP curriculum at national, local and individual learner levels.
2. Provide relevant, comprehensive and accessible learning content for GPs working in the UK.
3. Embody adult learning principles and support a blended approach to learning.
4. Support postgraduate doctors in training to become GPs.
5. Support GPs in Continual Professional Development (CPD) and revalidation.
The e-learning modules which are part of this programme include ‘What is the Menopause’, ‘Managing the Menopause’, ‘Hormone Replacement Therapy (HRT)’ and ‘Premature Menopause’.
Other menopause related online training includes:
• The Sexual and Reproductive Health (E-SRH) programme, developed in partnership with the Faculty of Sexual and Reproductive Healthcare (FSRH). The programme supports a range of healthcare professionals and compliments the redesigned FSRH Diploma (DFSRH) as well as other FSRH qualifications.
In recent years, the NHS England National Menopause programme has also launched a series of awareness sessions, including the ‘Menopause awareness’ and ‘Menopause and people professionals’ e-learning packages referenced earlier on in this response, as well as e-learning on ‘Menopause and occupational health’.
NHS England notes that some of the above training became available following Anne’s death, but hopes that this provides some reassurance to the Coroner and Anne’s family that additional resources have since been made available to healthcare practitioners and further improvements have been made to menopause care, training and resources.
Anne’s tragic death has highlighted important gaps in the care of women experiencing perimenopause or menopause and the potential for improvements. NHS England will continue to promote high quality and equitable coverage of menopause care for all.
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 Anne, 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.
The Trust has developed new supportive guidance for families regarding Section 17 leave, which is currently out for feedback and pending approval. They also detail existing support for menopausal training through Royal College resources and internal training, with further training dates being arranged.
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View full response
Dear Mrs Marsh
REGULATION 28 REPORT – PREVENTION OF FUTURE DEATHS – Jacqueline Anne Potter
I am writing in response to your correspondence dated 24 April 2025 regarding the Regulation 28 Notice of the Coroner’s (investigations) Regulations 2013 following the inquest regarding the death of Jacqueline Anne Potter which concluded on 7 March 2025.
We have set out the matters of concern as raised in the report below and our response to them.
MATTERS OF CONCERN
Part One
1. Lack of Risk and Safety Planning document for section 17 (MHA) leave
Following the concerns raised by the family and the coroner in Mrs Potter’s inquest, the Mental Health and Learning Disability Service group have developed supportive guidance for families and people who matter when a patient is on Section 17 Leave from an inpatient unit. This is currently out for feedback from teams and will be shared at the operational meeting next month for approval prior to production via the patient information team. We will also be sharing the draft document with service users and carers to ensure it covers the information that they feel is necessary to support them.
We believe that this document will provide additional support and information for families and people who matter to give them the knowledge to assist them with understanding the purpose of leave, their role and contact details should they require advice and guidance or emergency support.
The document sets out why Section 17 Leave is beneficial to patients, how and by whom it is granted, an explanation of risk assessments that are carried out ahead of leave, and what the role of the family member or carer is during that time.
The role of the family/carers is described as providing a safe and calm environment during the period of leave, encouragement of routines such as regular meals and medication, to act as a point of communication with any concerns to hospital staff and to assist the patient to return on time as agreed. There is also the option for the relative or carer to discuss any concerns with this level of responsibility, and to not accept it if they feel unsure or unable. There is also key information if they have concerns of who to Trust Management Headquarters Yeovil District Hospital Level 1 Peter.Lewis@somersetft.nhs.uk 30 June 2025 Mrs S Marsh c/o Somerset Coroner’s Court Sent via email to Trust Management Headquarters Yeovil District Hospital Higher Kingston Yeovil BA21 4AT
contact, what numbers to use and what concerns they may want to call the inpatient ward about if they are unsure.
The guidance stresses there is support available 24 hours a day, even if it is just to seek some guidance and who to contact in a more urgent situation.
2. Wi-Fi access whilst in an inpatient mental health unit
Following the inquest, further enquiries were made on this point within the Trust with our cyber security manager.
All Trust devices accessible to patients on our inpatient mental health units have parental control software installed which filters out inappropriate content and restricts access to harmful material. This is in addition to security features on our Wi-Fi which blocks certain categories from view as part of our web filtering policy. This is a Trust wide approach.
Additionally, some desktop devices in some inpatient mental health sites have a browser extension loaded onto the device which will divert users away from certain search terms to a free, 24/7 mental health support site. This can only be used on PCs and is not suitable for mobile devices, but it effectively blocks patients accessing this type of information when they use a search engine on a ward PC e.g. google, safari. Our IT team explained that they could not currently see that this programme is available to download onto mobile devices.
Private devices would not connect to the Trust Network, due to security reasons, and instead would connect to the public ‘NHS Wi-Fi’ which is essentially a connection straight out to the internet. Any changes made to this connection would have to be made county-wide and would affect all devices which connect to it.
The Trust has a Standard Operating Procedure for our mental health wards which outlines the parameters for use of Trust and personal IT equipment on the wards and includes guidance on when access to mobile phones and the internet may be restricted or withdrawn. The guidance lists considerations of risk related to the use of mobile phones, including if the patient has a history of accessing self-harm or suicide related websites.
Part 2
3. Menopause and Mental Health We have previously responded about the changes that have occurred at Somerset NHS FT over the last 2 years in relation to education and training around the link between mental health and menopause.
There is an ongoing task and finish group which is leading on this piece of work and has focused on improving clinicians understanding of what to look for, ask about and consider when assessing patient who may fit in this category. If there is a potential consideration, we add a prompt to our electronic patient record, Dialog+, to ask these questions. Whilst it is not expected that mental health clinicians will make a primary diagnosis of menopause we expect it to be on the list of considerations of patients who meet the criteria. For the clinician there must be consideration of what Mental Health and menopausal symptoms might look like, with an awareness of potential for overshadowing, and the need to establish a proper history from the patient. This is supported by the training offered by the Royal College of Psychiatrists and internal training.
We also recognise the importance of, and support colleagues to undertake, screening and signposting patients to other services and websites which offer support and guidance for those who may meet the criteria for menopause to be considered.. This includes the updated NICE guidance, Overview | Menopause: identification and management | Guidance | NICE. The 2024 update includes the consideration of psychological support for early menopause and cognitive behavioural therapy as a possible management option. There is also additional guidance on the use of HRT for the management of depressive symptoms, which do not meet the criteria for a diagnosis of depression, associated with menopause within the guidance which can provide a first line approach for GP’s managing patients and for mental health professionals to highlight in communication with the patient’s GP if they feel the patient meets this criteria.
We still have the benefit of having the Director of General Practice working at the Trust who is a specialist in menopause management. This is not something many secondary care providers have. Dr Patrick supports the mental health team and the wider trust in providing up to date education and support, which involves training sessions of what to look for and consider, and where to signpost. There are further dates for training for colleagues being arranged.
I hope that the above information has been helpful. Can I also take this opportunity to express, personally and on behalf of the Trust, my condolences to the family of Mrs Potter, for their loss.
Please do not hesitate to contact me if you require further information.
REGULATION 28 REPORT – PREVENTION OF FUTURE DEATHS – Jacqueline Anne Potter
I am writing in response to your correspondence dated 24 April 2025 regarding the Regulation 28 Notice of the Coroner’s (investigations) Regulations 2013 following the inquest regarding the death of Jacqueline Anne Potter which concluded on 7 March 2025.
We have set out the matters of concern as raised in the report below and our response to them.
MATTERS OF CONCERN
Part One
1. Lack of Risk and Safety Planning document for section 17 (MHA) leave
Following the concerns raised by the family and the coroner in Mrs Potter’s inquest, the Mental Health and Learning Disability Service group have developed supportive guidance for families and people who matter when a patient is on Section 17 Leave from an inpatient unit. This is currently out for feedback from teams and will be shared at the operational meeting next month for approval prior to production via the patient information team. We will also be sharing the draft document with service users and carers to ensure it covers the information that they feel is necessary to support them.
We believe that this document will provide additional support and information for families and people who matter to give them the knowledge to assist them with understanding the purpose of leave, their role and contact details should they require advice and guidance or emergency support.
The document sets out why Section 17 Leave is beneficial to patients, how and by whom it is granted, an explanation of risk assessments that are carried out ahead of leave, and what the role of the family member or carer is during that time.
The role of the family/carers is described as providing a safe and calm environment during the period of leave, encouragement of routines such as regular meals and medication, to act as a point of communication with any concerns to hospital staff and to assist the patient to return on time as agreed. There is also the option for the relative or carer to discuss any concerns with this level of responsibility, and to not accept it if they feel unsure or unable. There is also key information if they have concerns of who to Trust Management Headquarters Yeovil District Hospital Level 1 Peter.Lewis@somersetft.nhs.uk 30 June 2025 Mrs S Marsh c/o Somerset Coroner’s Court Sent via email to Trust Management Headquarters Yeovil District Hospital Higher Kingston Yeovil BA21 4AT
contact, what numbers to use and what concerns they may want to call the inpatient ward about if they are unsure.
The guidance stresses there is support available 24 hours a day, even if it is just to seek some guidance and who to contact in a more urgent situation.
2. Wi-Fi access whilst in an inpatient mental health unit
Following the inquest, further enquiries were made on this point within the Trust with our cyber security manager.
All Trust devices accessible to patients on our inpatient mental health units have parental control software installed which filters out inappropriate content and restricts access to harmful material. This is in addition to security features on our Wi-Fi which blocks certain categories from view as part of our web filtering policy. This is a Trust wide approach.
Additionally, some desktop devices in some inpatient mental health sites have a browser extension loaded onto the device which will divert users away from certain search terms to a free, 24/7 mental health support site. This can only be used on PCs and is not suitable for mobile devices, but it effectively blocks patients accessing this type of information when they use a search engine on a ward PC e.g. google, safari. Our IT team explained that they could not currently see that this programme is available to download onto mobile devices.
Private devices would not connect to the Trust Network, due to security reasons, and instead would connect to the public ‘NHS Wi-Fi’ which is essentially a connection straight out to the internet. Any changes made to this connection would have to be made county-wide and would affect all devices which connect to it.
The Trust has a Standard Operating Procedure for our mental health wards which outlines the parameters for use of Trust and personal IT equipment on the wards and includes guidance on when access to mobile phones and the internet may be restricted or withdrawn. The guidance lists considerations of risk related to the use of mobile phones, including if the patient has a history of accessing self-harm or suicide related websites.
Part 2
3. Menopause and Mental Health We have previously responded about the changes that have occurred at Somerset NHS FT over the last 2 years in relation to education and training around the link between mental health and menopause.
There is an ongoing task and finish group which is leading on this piece of work and has focused on improving clinicians understanding of what to look for, ask about and consider when assessing patient who may fit in this category. If there is a potential consideration, we add a prompt to our electronic patient record, Dialog+, to ask these questions. Whilst it is not expected that mental health clinicians will make a primary diagnosis of menopause we expect it to be on the list of considerations of patients who meet the criteria. For the clinician there must be consideration of what Mental Health and menopausal symptoms might look like, with an awareness of potential for overshadowing, and the need to establish a proper history from the patient. This is supported by the training offered by the Royal College of Psychiatrists and internal training.
We also recognise the importance of, and support colleagues to undertake, screening and signposting patients to other services and websites which offer support and guidance for those who may meet the criteria for menopause to be considered.. This includes the updated NICE guidance, Overview | Menopause: identification and management | Guidance | NICE. The 2024 update includes the consideration of psychological support for early menopause and cognitive behavioural therapy as a possible management option. There is also additional guidance on the use of HRT for the management of depressive symptoms, which do not meet the criteria for a diagnosis of depression, associated with menopause within the guidance which can provide a first line approach for GP’s managing patients and for mental health professionals to highlight in communication with the patient’s GP if they feel the patient meets this criteria.
We still have the benefit of having the Director of General Practice working at the Trust who is a specialist in menopause management. This is not something many secondary care providers have. Dr Patrick supports the mental health team and the wider trust in providing up to date education and support, which involves training sessions of what to look for and consider, and where to signpost. There are further dates for training for colleagues being arranged.
I hope that the above information has been helpful. Can I also take this opportunity to express, personally and on behalf of the Trust, my condolences to the family of Mrs Potter, for their loss.
Please do not hesitate to contact me if you require further information.
NICE clarifies that concerns regarding risk/safety planning documents are not explicitly covered by their guidance, but existing guidelines stress family involvement. They state concerns about menopause training and services fall outside their direct remit and that their surveillance team is satisfied current menopause guidelines are up to date.
AI summary
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Dear Ms Marsh, Re: Regulation 28 Prevention of Future Deaths Report in respect of Jaqueline Anne Potter I write in response to your regulation 28 report, dated 24 April 2025, regarding the very sad death of Anne Potter. I would like to express my sincere condolences to Anne’s family. We would like to thank you for including NICE in this important report. We have reflected on the circumstances surrounding Anne’s death and the concerns raised. We note there are five distinct concerns raised in your report. It is important to note from the outset that we do not consider the concerns raised are directly attributable to NICE, but note your report is also addressed to NHS England, Somerset NHS Foundation Trust, the Royal College of Obstetricians and Gynaecologists and the Royal College of General Practitioners. We have outlined the concerns below, detailing NICE’s response to each in turn.
1. The lack of a codified ‘Risk’ and ‘Safety Planning’ document to be given to relatives and carers to assist families in spotting early warning signs that ‘something is wrong’ and to seek help and intervention (if/when appropriate) to minimise the risk of a patient taking their own life whilst in the community. We do not believe there is any NICE guidance that explicitly covers this matter, but our quality standard suicide prevention [QS189], quality statement 4, stresses the importance of asking the person if they would like their family, carers or friends to be involved in their care. The NICE guideline, self-harm: assessment, management and preventing recurrence [NG225] also has a number of recommendations that are not entirely specific to this situation, but that indicate an approach of involving the family and carers (with the person’s consent) and providing written materials. For instance:
1.10.1 ‘After an episode of self-harm, discuss and agree with the person, and their family members and carers (as appropriate), the purpose, format and frequency of initial aftercare and which services will be involved in their care. Record this in the person's care plan and ensure that the person and their family members and carers have a copy of the plan and contact details for the team providing the aftercare’ (my emphasis).
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1.5.15 ‘Together with the person who self-harms and their family and carers (if appropriate), develop or review a care plan using the key areas of needs and safety considerations identified in the psychosocial assessment’
1.4.1 ‘Be aware that even if the person has not consented to involving their family or carers in their care, family members or carers can still provide information about the person’. Our guidance emphasises the importance of involving family and carers, and of providing written information. We do not specifically mention the document or circumstances outlined in this report, but NICE’s recommendations are not intended to cover all clinical circumstances.
2. Wi-Fi access to harmful websites whilst in NHS facilities. NICE does not have responsibility for managing NHS care or services and therefore we would be unable to comment on this concern.
3. No compulsory training in menopause Again, we do not consider that this concern is directly for NICE as we are not responsible for setting the curriculum for undergraduate and trainee doctors in the UK, this is the role of the General Medical Council (GMC). We understand that there is currently work being done to integrate menopause care into both GP and specialist training curricula, with menopause as part of the GP Specialty Training Curriculum (although still not a standalone module) and the RCOG launching a Special Interest Training Module (SITM) in Menopause Care in 2024. However, only a very small number of trainees will access this. It is the view of our consultant clinical advisers that menopause care is not consistently or comprehensively taught across all UK medical schools, and there is no national standard requiring in-depth menopause training for all medical students. You may wish to share this part of the report with the General Medical Council (GMC) and with Health Education England (part of NHS England) for their consideration.
4. Lack of menopause specialists or menopause services in the NHS We believe this concern will be better answered by NHS England and the Royal Colleges.
5. There has not been a roll-out of specialist menopausal care and upskilling of GPs, as was promised in a previous PFD. As noted above, we believe this concern will be better answered by NHS England and the Royal Colleges. We note your report also mentions a previous prevention of future death report sent to NICE, NHS England and Somerset NHS Foundation Trust in June 2024 on a similar matter. Within our response, sent in August 2024, we stated that following publication of the menopause update in November 2024, we would assess if any further changes relating to mental health and menopause are needed, in response to the HSIB recommendation and taking into account the issues raised in the initial PFD. NICE’s surveillance team have informed us that ‘With the updates that have been made to menopause: identification and management [NG23] in November 2024 and the conclusions of the 2023 surveillance review, we are satisfied NG23 and the mental health guidelines are
Page | 3
up to date in relation to the HSIB report. We are tracking studies in this area identified by the 2023 surveillance, so this topic will remain on surveillance’s radar’. I hope this response has helped outline our role and the recommendations that are in place on this important topic. I would like to reiterate my sincere condolences to Anne’s family.
1. The lack of a codified ‘Risk’ and ‘Safety Planning’ document to be given to relatives and carers to assist families in spotting early warning signs that ‘something is wrong’ and to seek help and intervention (if/when appropriate) to minimise the risk of a patient taking their own life whilst in the community. We do not believe there is any NICE guidance that explicitly covers this matter, but our quality standard suicide prevention [QS189], quality statement 4, stresses the importance of asking the person if they would like their family, carers or friends to be involved in their care. The NICE guideline, self-harm: assessment, management and preventing recurrence [NG225] also has a number of recommendations that are not entirely specific to this situation, but that indicate an approach of involving the family and carers (with the person’s consent) and providing written materials. For instance:
1.10.1 ‘After an episode of self-harm, discuss and agree with the person, and their family members and carers (as appropriate), the purpose, format and frequency of initial aftercare and which services will be involved in their care. Record this in the person's care plan and ensure that the person and their family members and carers have a copy of the plan and contact details for the team providing the aftercare’ (my emphasis).
Page | 2
1.5.15 ‘Together with the person who self-harms and their family and carers (if appropriate), develop or review a care plan using the key areas of needs and safety considerations identified in the psychosocial assessment’
1.4.1 ‘Be aware that even if the person has not consented to involving their family or carers in their care, family members or carers can still provide information about the person’. Our guidance emphasises the importance of involving family and carers, and of providing written information. We do not specifically mention the document or circumstances outlined in this report, but NICE’s recommendations are not intended to cover all clinical circumstances.
2. Wi-Fi access to harmful websites whilst in NHS facilities. NICE does not have responsibility for managing NHS care or services and therefore we would be unable to comment on this concern.
3. No compulsory training in menopause Again, we do not consider that this concern is directly for NICE as we are not responsible for setting the curriculum for undergraduate and trainee doctors in the UK, this is the role of the General Medical Council (GMC). We understand that there is currently work being done to integrate menopause care into both GP and specialist training curricula, with menopause as part of the GP Specialty Training Curriculum (although still not a standalone module) and the RCOG launching a Special Interest Training Module (SITM) in Menopause Care in 2024. However, only a very small number of trainees will access this. It is the view of our consultant clinical advisers that menopause care is not consistently or comprehensively taught across all UK medical schools, and there is no national standard requiring in-depth menopause training for all medical students. You may wish to share this part of the report with the General Medical Council (GMC) and with Health Education England (part of NHS England) for their consideration.
4. Lack of menopause specialists or menopause services in the NHS We believe this concern will be better answered by NHS England and the Royal Colleges.
5. There has not been a roll-out of specialist menopausal care and upskilling of GPs, as was promised in a previous PFD. As noted above, we believe this concern will be better answered by NHS England and the Royal Colleges. We note your report also mentions a previous prevention of future death report sent to NICE, NHS England and Somerset NHS Foundation Trust in June 2024 on a similar matter. Within our response, sent in August 2024, we stated that following publication of the menopause update in November 2024, we would assess if any further changes relating to mental health and menopause are needed, in response to the HSIB recommendation and taking into account the issues raised in the initial PFD. NICE’s surveillance team have informed us that ‘With the updates that have been made to menopause: identification and management [NG23] in November 2024 and the conclusions of the 2023 surveillance review, we are satisfied NG23 and the mental health guidelines are
Page | 3
up to date in relation to the HSIB report. We are tracking studies in this area identified by the 2023 surveillance, so this topic will remain on surveillance’s radar’. I hope this response has helped outline our role and the recommendations that are in place on this important topic. I would like to reiterate my sincere condolences to Anne’s family.
The RCOG states its core O&G training curriculum and MRCOG examination already cover menopause management as a key skill. It also provides a Special Interest Training Module in menopause care and offers a Diploma for GPs, which includes menopause, in addition to hosting various related educational events.
AI summary
View full response
Dear Ms Marsh,
Re: Jacqueline Anne Potter
Thank you for your Regulation 28 Report to Prevent Future deaths following the inquest into the death of Jacqueline Anne Potter on 24 April 2025.
This loss is a devastating tragedy for the immediate and the wider family, and the healthcare professionals involved. We would like to begin by extending our deepest and heartfelt condolences to Anne’s family for their profound loss.
This response has been developed following input from members of the Royal College of Obstetricians and Gynaecologists (RCOG) Patient Safety Committee and Senior Officers of the College.
We recognise and respect the narrative conclusion from the inquest that Anne died from multiple traumatic injuries through suicide, secondary to her menopausal symptoms contributing to her mental health decline and exacerbation of her underlying anxiety.
We also recognise the matters of concern as outlined in your letter as follows, ‘Certain elements of medicine and clinical practice training are compulsory but having heard evidence at the Inquest around mandatory and statutory training modules I learnt that this covers areas such as GDPR training and disposal of sharp objects such as syringes. I was surprised to learn that menopausal training is not mandatory in any area of clinical practice or specialism. I am concerned that there is no requirement to undertake essential compulsory menopausal training for those working in ‘relevant’ clinical practices such as Mental Health Practice, Obstetrics and Gynaecology and Oncology, or even general as a general GP’.
At present, it is only a requirement for doctors on the General Medical Council’s specialist register for obstetrics and gynaecology to have demonstrated competency in menopausal and postmenopausal care.
To support doctors in this aim, the RCOG provides educational initiatives, including its curricula on which the MRCOG qualification is based and tested through examinations, elevating care standards through clinical guidance, assisting in career advancement through examinations, coordinating professional development initiatives and events, and offering support services to its members.
The RCOG’s core training curriculum which provides a framework for the training of Obstetricians and Gynaecologists ensures that management of the menopause is covered as a key skill. Understanding and management of the menopause is a key area on the syllabus for the MRCOG examination, which is an essential qualification in our speciality.
The College also has a Special Interest Training Module (SITM) in menopause care. This SITM is aimed at learners with an interest in menopause care. It provides training on how to assess and investigate women with menopause-related symptoms, understand the benefits and risks of HRT and alternative therapies, and counsel and advise women accordingly.
Additionally, for General Practitioners who would like to develop a more advanced knowledge of women’s healthcare, the RCOG also provides the Diploma of the Royal College of Obstetricians and Gynaecologists (DRCOG). The core syllabus for this examination also includes diagnosis, investigation and management of the menopause. The DRCOG is primarily undertaken by those in General Practice who have an interest in Women’s Health but is not mandatory.
Throughout the course of each year the RCOG and our Specialist Society (British Menopause Society) also host numerous training and education events which are accessible to all healthcare professionals, several of which support additional education into various aspects of care for menopausal women.
I hope this is a helpful response to this matter.
Re: Jacqueline Anne Potter
Thank you for your Regulation 28 Report to Prevent Future deaths following the inquest into the death of Jacqueline Anne Potter on 24 April 2025.
This loss is a devastating tragedy for the immediate and the wider family, and the healthcare professionals involved. We would like to begin by extending our deepest and heartfelt condolences to Anne’s family for their profound loss.
This response has been developed following input from members of the Royal College of Obstetricians and Gynaecologists (RCOG) Patient Safety Committee and Senior Officers of the College.
We recognise and respect the narrative conclusion from the inquest that Anne died from multiple traumatic injuries through suicide, secondary to her menopausal symptoms contributing to her mental health decline and exacerbation of her underlying anxiety.
We also recognise the matters of concern as outlined in your letter as follows, ‘Certain elements of medicine and clinical practice training are compulsory but having heard evidence at the Inquest around mandatory and statutory training modules I learnt that this covers areas such as GDPR training and disposal of sharp objects such as syringes. I was surprised to learn that menopausal training is not mandatory in any area of clinical practice or specialism. I am concerned that there is no requirement to undertake essential compulsory menopausal training for those working in ‘relevant’ clinical practices such as Mental Health Practice, Obstetrics and Gynaecology and Oncology, or even general as a general GP’.
At present, it is only a requirement for doctors on the General Medical Council’s specialist register for obstetrics and gynaecology to have demonstrated competency in menopausal and postmenopausal care.
To support doctors in this aim, the RCOG provides educational initiatives, including its curricula on which the MRCOG qualification is based and tested through examinations, elevating care standards through clinical guidance, assisting in career advancement through examinations, coordinating professional development initiatives and events, and offering support services to its members.
The RCOG’s core training curriculum which provides a framework for the training of Obstetricians and Gynaecologists ensures that management of the menopause is covered as a key skill. Understanding and management of the menopause is a key area on the syllabus for the MRCOG examination, which is an essential qualification in our speciality.
The College also has a Special Interest Training Module (SITM) in menopause care. This SITM is aimed at learners with an interest in menopause care. It provides training on how to assess and investigate women with menopause-related symptoms, understand the benefits and risks of HRT and alternative therapies, and counsel and advise women accordingly.
Additionally, for General Practitioners who would like to develop a more advanced knowledge of women’s healthcare, the RCOG also provides the Diploma of the Royal College of Obstetricians and Gynaecologists (DRCOG). The core syllabus for this examination also includes diagnosis, investigation and management of the menopause. The DRCOG is primarily undertaken by those in General Practice who have an interest in Women’s Health but is not mandatory.
Throughout the course of each year the RCOG and our Specialist Society (British Menopause Society) also host numerous training and education events which are accessible to all healthcare professionals, several of which support additional education into various aspects of care for menopausal women.
I hope this is a helpful response to this matter.
Kenny & Murphy Ltd states they sold the incident site in March 2024 and have no influence over those tenants. For the sites they currently own, they have assessed them for differences and have taken steps to discuss electricity safety concerns with tenants, providing them with NGED and HSE safety documents.
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Dear Madam Coroner
I confirm receipt of and the following action in respect of the Regulation 28 Report to Prevent Future Deaths dated 26 June 2025 and your concerns.
Kenny & Murphy Ltd sold the incident site together with the main part of the Estate in March, 2024 and so have no influence over those tenants. Kenny & Murphy Ltd currently own one site at Bridgwater and a 50% interest in two sites at Southampton. We have undertaken an assessment on all three sites and submit that they differ from the incident site as they only have one tenant per site and there are no shared areas outside of their individual control and responsibility. None of the sites has any H Pole within its boundary or any transformer to handle incoming electricity at the same 11000v level. However, I have taken steps to discuss with the tenants the concerns raised by yourself regarding working safely around electricity and have also provided the tenants with the NGED "Stay Away Stay Safe!" leaflet and a copy of the HSE Electricity at Work Safe Working Practice document HSG85.
I trust that this complies with my responsibilities in accordance with the PFD Report.
I confirm receipt of and the following action in respect of the Regulation 28 Report to Prevent Future Deaths dated 26 June 2025 and your concerns.
Kenny & Murphy Ltd sold the incident site together with the main part of the Estate in March, 2024 and so have no influence over those tenants. Kenny & Murphy Ltd currently own one site at Bridgwater and a 50% interest in two sites at Southampton. We have undertaken an assessment on all three sites and submit that they differ from the incident site as they only have one tenant per site and there are no shared areas outside of their individual control and responsibility. None of the sites has any H Pole within its boundary or any transformer to handle incoming electricity at the same 11000v level. However, I have taken steps to discuss with the tenants the concerns raised by yourself regarding working safely around electricity and have also provided the tenants with the NGED "Stay Away Stay Safe!" leaflet and a copy of the HSE Electricity at Work Safe Working Practice document HSG85.
I trust that this complies with my responsibilities in accordance with the PFD Report.
Report Sections
Investigation and Inquest
On 6th December 2022 I commenced an investigation into the death of Jacqueline Anne Potter, aged 54, (known as “Anne”). The investigation concluded at the end of the inquest on the 10th March 2025. The conclusion of the jury inquest was a short form conclusion of Suicide in box 4.
The Jury’s answer to ‘when, where and how’ was recorded in box 3 of the Record of Inquest as follows:
“Anne was a 54 year old menopausal woman experiencing a number of stresses in her life. The menopause contributed to her mental health decline and exacerbated her underlying anxiety. On the 27th September 2002, Anne took an overdose of paracetamol. She was taken to Yeovil District Hospital where she received treatment. She then received daily community mental health support. After found wandering in traffic and absconding from her home, on the 20th October 2022, she agreed to a voluntary admission to Rowan Ward. She was then detained on a section 5(2) of the Mental Health Act. On the 21st October 2022 this was upgraded to a section 2 detention. On the 24th October 2022, she was granted her first Section 17 Leave. On the 31st October 2022, on a walk with a Health Care Assistant, Anne attempted to run into the road. On the 16th November 2022, due to a number of incidents and no possible community support options, she was upgraded to a Section 3 detention. During her review on the 29th November 2022, Anne was authorised for Section 17 Leave for an overnight stay at home on the 4th December 2022. On the 3rd December 2022 she had a day with her family in Bristol. On the morning of the 4th December 2022, following staff assessment of Anne, the overnight leave was granted. Anne’s family did not receive appropriate information to assist them in keeping Anne safe for an overnight stay. She went home on the 4th December 2022 and in the morning of the Fifth December 2022 Anne used a key to open the back door, took a car key and drove away. Anne was driving on the Eastbound carriageway of the A303 and at 07:48 she deliberately drove into the path of a HGV tank lorry on the opposite carriageway.”
The medical cause of death was recorded as: Ia) Multiple traumatic injuries
The Jury’s answer to ‘when, where and how’ was recorded in box 3 of the Record of Inquest as follows:
“Anne was a 54 year old menopausal woman experiencing a number of stresses in her life. The menopause contributed to her mental health decline and exacerbated her underlying anxiety. On the 27th September 2002, Anne took an overdose of paracetamol. She was taken to Yeovil District Hospital where she received treatment. She then received daily community mental health support. After found wandering in traffic and absconding from her home, on the 20th October 2022, she agreed to a voluntary admission to Rowan Ward. She was then detained on a section 5(2) of the Mental Health Act. On the 21st October 2022 this was upgraded to a section 2 detention. On the 24th October 2022, she was granted her first Section 17 Leave. On the 31st October 2022, on a walk with a Health Care Assistant, Anne attempted to run into the road. On the 16th November 2022, due to a number of incidents and no possible community support options, she was upgraded to a Section 3 detention. During her review on the 29th November 2022, Anne was authorised for Section 17 Leave for an overnight stay at home on the 4th December 2022. On the 3rd December 2022 she had a day with her family in Bristol. On the morning of the 4th December 2022, following staff assessment of Anne, the overnight leave was granted. Anne’s family did not receive appropriate information to assist them in keeping Anne safe for an overnight stay. She went home on the 4th December 2022 and in the morning of the Fifth December 2022 Anne used a key to open the back door, took a car key and drove away. Anne was driving on the Eastbound carriageway of the A303 and at 07:48 she deliberately drove into the path of a HGV tank lorry on the opposite carriageway.”
The medical cause of death was recorded as: Ia) Multiple traumatic injuries
Circumstances of the Death
Anne first presented to her GP in 2008. During this year she had three separate appointments relating to underlying anxiety and being unable to cope. There was no secondary mental health service involvement, nor was there any prescription of anti-depressants at this time. Anne presented to the GP again in 2014, so six years later. Her presentation at this time was felt by the GP to be a grief/bereavement reaction.
From early 2017 up to the end of 2019 there were five separate consultations for gynaecological and/or gastroenterological presentations but despite secondary investigations, no underlying physiological cause was found and the GP felt that there was a high possibility that her tummy and bowel issues were related to her underlying anxiety.
On the 18th December 2020, Anne had her first significant consultation about mental health symptoms. She was extremely anxious and low in mood and stressed with life in general. On the 11th January 2021 Anne was emotionally fragile, anxious and stressed. This was the first consultation at which menopause (or perimenopause) was mentioned. Given her presentation it would appear that her underling anxiety had been slowly building; possibly since 2008 but much more so since 2017. Anne started taking Sertraline in February 2021 (she was prescribed this in the January but was too anxious about side effects to start taking it). She was also started on HRT.
By the end of May 2021 her symptoms appeared to be under control but it was impossibly to know if this was the Sertraline, the HRT or a combination of both. In July of 2021, following consultation with her GP, the dose of Sertraline was titrated down so that by the Autumn of 2021 she had stopped taking this medication altogether.
In early September 2022, Anne’s presentation declined again and she agreed to re-start Sertraline. On the 27th September 2022 Anne was at home with her husband when she informed him she’d taken tablets. This was the first time Anne had done anything like this before and it was very much the start of her acute decline. After discharge from hospital she was seen daily by the mental health team, and declined an admission.
On the 20th October 2022, Anne did agree to a voluntary admission to an acute psychiatric unit. This was after she had been returned home by the police who responded to a member of the public who had called in after finding her wandering in traffic. Anne was detained under section 5(2) of the Mental Health Act. She remained detained up till the date of her death; being placed on a Section 2 detention and this was upgraded to a Section 3 detention on the 16th November 2022. Anne had a devoted and supportive husband and family, who were keen to be involved in her care and recovery; so much so that Anne started taking section 17 leave from the 24th October 2022 (3 days after she was detained). She would take escorted leave with either the staff or her husband in the local area for a couple of hours (gradually increasing to up to 6 hours at a time).
On the 31st October 2022 whilst out with staff Anne ran into the road and was pulled back by the Health Care Assistant. It was never established what Anne was actually trying to do on this occasion; whether she was trying to harm herself or whether she was simply trying to avoid going back to the ward as she did not like the ward environment and had said that she would rather be at home with her husband. She remained on the ward without leave for three days after this incident.
On the 29th November 2022 an MDT (Multi Disciplinary Meeting) took place. At this meeting section 17 overnight leave was authorised for the 4th December 2022 on the basis that there had been no incidents of risky behaviour and/or absconding (with the exception of the 31st October 2022) and since that incident leave between the 4th and 29th November 2022 had gone ‘well’. Both Anne and her husband were keen for overnight leave and it was felt entirely appropriate to support this wish as part of her recovery.
Anne went out for 6 hours on the 3rd December 2022 to a Christmas market in Bristol with her husband. This leave went well and without incident. Anne appeared brighter; she was showing future planning with her family for the forthcoming Christmas period and was commenting on finding pleasure and enjoyment in things again (the mental health team highlighted her enjoyment at watching Strictly Come Dancing which whilst small, highlighted a departure from her previous anhedonia).
Anne was assessed by a mental health nurse prior to her overnight leave on the 4th December 2022. There were no concerning or alarming features or presentation that would have given the nurse (or the entire mental health team involved in her care) any clinical reason to withhold her planned leave. The entire treating team were all very clear that there was no reason to not “let her out” that day. Her husband came to collect her at just after 10am that morning. He was not given any formal or codified ‘Risk Assessment’ document, but he had been very heavily involved in his wife’s care and treatment every step of the way and so the evidence was clear; even if he had been given such a document it would not have contained any information or details that wasn’t already within his knowledge.
Overnight the leave appeared to go well. Anne’s husband had locked the doors and windows and hidden those keys in a desk drawer. He did not hide the car keys as he did not think for one minute that his wife would take the car. That morning Anne found the back door key in the desk drawer and took the car. She was seen driving erratically by multiple other road users who were travelling eastbound on the A303 that morning. At around 07:48 Anne drove her car into the path of a fully laden HGV tanker travelling on the westbound carriageway. There was nothing the tanker driver could have done to avoid the collision. Anne died instantly of multiple traumatic injuries.
It came to light after Anne’s death that she had been using her own personal device (mobile or tablet) to access websites pertaining to self harm. It is unknown whether she had accessed the psychiatric unit’s wifi or whether she had made searches using her own personal data from her phone provider contract.
From early 2017 up to the end of 2019 there were five separate consultations for gynaecological and/or gastroenterological presentations but despite secondary investigations, no underlying physiological cause was found and the GP felt that there was a high possibility that her tummy and bowel issues were related to her underlying anxiety.
On the 18th December 2020, Anne had her first significant consultation about mental health symptoms. She was extremely anxious and low in mood and stressed with life in general. On the 11th January 2021 Anne was emotionally fragile, anxious and stressed. This was the first consultation at which menopause (or perimenopause) was mentioned. Given her presentation it would appear that her underling anxiety had been slowly building; possibly since 2008 but much more so since 2017. Anne started taking Sertraline in February 2021 (she was prescribed this in the January but was too anxious about side effects to start taking it). She was also started on HRT.
By the end of May 2021 her symptoms appeared to be under control but it was impossibly to know if this was the Sertraline, the HRT or a combination of both. In July of 2021, following consultation with her GP, the dose of Sertraline was titrated down so that by the Autumn of 2021 she had stopped taking this medication altogether.
In early September 2022, Anne’s presentation declined again and she agreed to re-start Sertraline. On the 27th September 2022 Anne was at home with her husband when she informed him she’d taken tablets. This was the first time Anne had done anything like this before and it was very much the start of her acute decline. After discharge from hospital she was seen daily by the mental health team, and declined an admission.
On the 20th October 2022, Anne did agree to a voluntary admission to an acute psychiatric unit. This was after she had been returned home by the police who responded to a member of the public who had called in after finding her wandering in traffic. Anne was detained under section 5(2) of the Mental Health Act. She remained detained up till the date of her death; being placed on a Section 2 detention and this was upgraded to a Section 3 detention on the 16th November 2022. Anne had a devoted and supportive husband and family, who were keen to be involved in her care and recovery; so much so that Anne started taking section 17 leave from the 24th October 2022 (3 days after she was detained). She would take escorted leave with either the staff or her husband in the local area for a couple of hours (gradually increasing to up to 6 hours at a time).
On the 31st October 2022 whilst out with staff Anne ran into the road and was pulled back by the Health Care Assistant. It was never established what Anne was actually trying to do on this occasion; whether she was trying to harm herself or whether she was simply trying to avoid going back to the ward as she did not like the ward environment and had said that she would rather be at home with her husband. She remained on the ward without leave for three days after this incident.
On the 29th November 2022 an MDT (Multi Disciplinary Meeting) took place. At this meeting section 17 overnight leave was authorised for the 4th December 2022 on the basis that there had been no incidents of risky behaviour and/or absconding (with the exception of the 31st October 2022) and since that incident leave between the 4th and 29th November 2022 had gone ‘well’. Both Anne and her husband were keen for overnight leave and it was felt entirely appropriate to support this wish as part of her recovery.
Anne went out for 6 hours on the 3rd December 2022 to a Christmas market in Bristol with her husband. This leave went well and without incident. Anne appeared brighter; she was showing future planning with her family for the forthcoming Christmas period and was commenting on finding pleasure and enjoyment in things again (the mental health team highlighted her enjoyment at watching Strictly Come Dancing which whilst small, highlighted a departure from her previous anhedonia).
Anne was assessed by a mental health nurse prior to her overnight leave on the 4th December 2022. There were no concerning or alarming features or presentation that would have given the nurse (or the entire mental health team involved in her care) any clinical reason to withhold her planned leave. The entire treating team were all very clear that there was no reason to not “let her out” that day. Her husband came to collect her at just after 10am that morning. He was not given any formal or codified ‘Risk Assessment’ document, but he had been very heavily involved in his wife’s care and treatment every step of the way and so the evidence was clear; even if he had been given such a document it would not have contained any information or details that wasn’t already within his knowledge.
Overnight the leave appeared to go well. Anne’s husband had locked the doors and windows and hidden those keys in a desk drawer. He did not hide the car keys as he did not think for one minute that his wife would take the car. That morning Anne found the back door key in the desk drawer and took the car. She was seen driving erratically by multiple other road users who were travelling eastbound on the A303 that morning. At around 07:48 Anne drove her car into the path of a fully laden HGV tanker travelling on the westbound carriageway. There was nothing the tanker driver could have done to avoid the collision. Anne died instantly of multiple traumatic injuries.
It came to light after Anne’s death that she had been using her own personal device (mobile or tablet) to access websites pertaining to self harm. It is unknown whether she had accessed the psychiatric unit’s wifi or whether she had made searches using her own personal data from her phone provider contract.
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following
Inquest Conclusion
“Anne was a 54 year old menopausal woman experiencing a number of stresses in her life. The menopause contributed to her mental health decline and exacerbated her underlying anxiety. On the 27th September 2002, Anne took an overdose of paracetamol. She was taken to Yeovil District Hospital where she received treatment. She then received daily community mental health support. After found wandering in traffic and absconding from her home, on the 20th October 2022, she agreed to a voluntary admission to Rowan Ward. She was then detained on a section 5(2) of the Mental Health Act. On the 21st October 2022 this was upgraded to a section 2 detention. On the 24th October 2022, she was granted her first Section 17 Leave. On the 31st October 2022, on a walk with a Health Care Assistant, Anne attempted to run into the road. On the 16th November 2022, due to a number of incidents and no possible community support options, she was upgraded to a Section 3 detention. During her review on the 29th November 2022, Anne was authorised for Section 17 Leave for an overnight stay at home on the 4th December 2022. On the 3rd December 2022 she had a day with her family in Bristol. On the morning of the 4th December 2022, following staff assessment of Anne, the overnight leave was granted. Anne’s family did not receive appropriate information to assist them in keeping Anne safe for an overnight stay. She went home on the 4th December 2022 and in the morning of the Fifth December 2022 Anne used a key to open the back door, took a car key and drove away. Anne was driving on the Eastbound carriageway of the A303 and at 07:48 she deliberately drove into the path of a HGV tank lorry on the opposite carriageway.”
The medical cause of death was recorded as: Ia) Multiple traumatic injuries
The medical cause of death was recorded as: Ia) Multiple traumatic injuries
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.