Melanie Pinnell
PFD Report
All Responded
Ref: 2026-0185
All 1 response received
· Deadline: 21 May 2026
Coroner's Concerns (AI summary)
No follow-up was offered to the deceased by the GP practice after she described suicidal ideation and suicidal thoughts; a Consultant Psychiatrist's request for Sertraline was not actioned by a GP, posing a risk to patient safety.
View full coroner's concerns
During the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In these circumstances it is my statutory duty to report to you: MATTERS OF CONCERN No follow-up was offered to Melanie by the GP practice after February 2025 despite Melanie describing suicidal ideation and suicidal thoughts The request for Sertraline 50mg once a day given by a Consultant Psychiatrist to the Primary Care Network Mental Health Care Worker was not actioned by a GP working for Unity Healthcare Both pose a significant risk to patient safety.
Responses
Action Taken
• Following this incident, Unity Healthcare commissioned a comprehensive Patient Safety Incident Investigation (PSII) in accordance with the NHS Patient Safety Incident Response Framework (PSIRF). • The investigation utilised system-based analytical tools, including the Systems Engineering Initiative for Patient Safety (SEIPS) and the Yorkshire Contributory Factors Framework. (AI summary)
• Following this incident, Unity Healthcare commissioned a comprehensive Patient Safety Incident Investigation (PSII) in accordance with the NHS Patient Safety Incident Response Framework (PSIRF). • The investigation utilised system-based analytical tools, including the Systems Engineering Initiative for Patient Safety (SEIPS) and the Yorkshire Contributory Factors Framework. (AI summary)
View full response
Suffolk GP Federation CIC Riverside Clinic, 2 Landseer Road, Ipswich, IP3 0AZ
Suffolk GP Federation CIC Registered in the UK. Registration number: 06183049 Registered address: Riverside Clinic, 2 Landseer Road, Ipswich, IP3 0AZ Reg. No: 1-140317426
Response to Report to Prevent Future Deaths
THIS RESPONSE IS BEING SENT TO: Daniel SHARPSTONE, Assistant Coroner for the coroner area of Suffolk.
1. Respondent Clinical Director, Unity Healthcare. In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, Unity Healthcare provides this response to the Report to Prevent Future Deaths.
2. Date of response Wednesday 13th May 2026
3. Confirmation of coroner’s matters of concern Unity Healthcare formally acknowledges the two matters of concern raised following the inquest into the death of Melanie Ruth Pinnell: ▪ No follow-up was offered to Melanie by the GP practice after February 2025 despite Melanie describing suicidal ideation and suicidal thoughts. ▪ The request for Sertraline once a day given by a Consultant Psychiatrist to the Primary Care Network Mental Health Care Worker was not actioned by a GP working for Unity Healthcare.
4. Investigation and reflection Unity Healthcare wishes to express its deepest sympathies to the family and friends of Melanie Pinnell. Following this incident, we commissioned a comprehensive Patient Safety Incident Investigation (PSII) in accordance with the NHS Patient Safety Incident Response Framework (PSIRF). The investigation utilised system-based analytical tools, including the Systems Engineering Initiative for Patient Safety (SEIPS) and the Yorkshire
Suffolk GP Federation CIC Riverside Clinic, 2 Landseer Road, Ipswich, IP3 0AZ Tel: 0345 2413313 Email: info@suffolkfed.org.uk Web: www.suffolkfed.org.uk
Suffolk GP Federation CIC Registered in the UK. Registration number: 06183049 Registered address: Riverside Clinic, 2 Landseer Road, Ipswich, IP3 0AZ Reg. No: 1-140317426 Contributory Factors Framework (YCFF). We engaged openly with the Norfolk and Suffolk Foundation Trust (NSFT) and the Primary Care Network (PCN) to fully understand the systemic vulnerabilities that contributed to this outcome. The investigation concluded that the incident arose from a combination of interacting system factors rather than individual error. Specifically, the required protocol for prescribing queries (the "pink internal query hub slot") was bypassed in favour of an individual "task," making the clinical request invisible to the wider team. Furthermore, complex organisational boundaries between the Practice, PCN, and the Norfolk and Suffolk NHS Foundation Trust (NSFT) resulted in gaps in accountability for actioning specialist advice and a lack of systematic safety-netting for vulnerable patients.
5. Details of action taken or proposed Based on our PSII findings, we are implementing the following safety actions with specific oversight and timelines: Addressing Concern 1: Gaps in Follow-up and Safety-Netting ▪ Formal Caseload Reviews: We are introducing a formal caseload review between the practice and the Mental Health team to review plans and safety- net actions. This is owned by the PCN MH Service Lead and GP Clinical Lead for mental health. ▪ Managing Uncontactable Patients: We are standardising the process for managing uncontactable patients by developing and implementing a new Standard Operating Procedure (SOP). Addressing Concern 2: Un-actioned Prescription Requests and Task Limitations ▪ Removing Task-Based Prescribing: We are removing the use of the task system for prescribing requests entirely and developing an approved, formal pathway SOP. ▪ System Recording: To ensure visibility, all specialist advice will be recorded in both of our clinical systems, SystmOne and Lorenzo. ▪ Defining Ownership and Escalation: The PCN MH Clinical Lead and GP Clinical Lead for mental health are defining and re-enforcing clear ownership for prescribing actions and follow-up, as well as introducing a formal escalation SOP for incomplete actions.
Suffolk GP Federation CIC Riverside Clinic, 2 Landseer Road, Ipswich, IP3 0AZ Tel: 0345 2413313 Email: info@suffolkfed.org.uk Web: www.suffolkfed.org.uk
Suffolk GP Federation CIC Registered in the UK. Registration number: 06183049 Registered address: Riverside Clinic, 2 Landseer Road, Ipswich, IP3 0AZ Reg. No: 1-140317426 Outstanding Task Review System: A review system for outstanding tasks— specifically ensuring visibility of tasks assigned to locums, absent staff, or staff who have left the organisation—was implemented by Clinical Services Management in June
2025.
6. Shared learning To ensure wide-reaching impact, the findings and new SOPs will be presented internally at Unity Healthcare clinical meetings. Furthermore, an anonymised summary detailing the risks of task-based messaging for prescribing requests will be shared with the Suffolk and North East Essex Integrated Care Board (ICB) Quality Lead to promote shared learning across the wider system.
7. Statement of truth I believe the facts stated in this response are true to the best of my knowledge and belief.
Clinical Director, Unity Healthcare
Suffolk GP Federation CIC Registered in the UK. Registration number: 06183049 Registered address: Riverside Clinic, 2 Landseer Road, Ipswich, IP3 0AZ Reg. No: 1-140317426
Response to Report to Prevent Future Deaths
THIS RESPONSE IS BEING SENT TO: Daniel SHARPSTONE, Assistant Coroner for the coroner area of Suffolk.
1. Respondent Clinical Director, Unity Healthcare. In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, Unity Healthcare provides this response to the Report to Prevent Future Deaths.
2. Date of response Wednesday 13th May 2026
3. Confirmation of coroner’s matters of concern Unity Healthcare formally acknowledges the two matters of concern raised following the inquest into the death of Melanie Ruth Pinnell: ▪ No follow-up was offered to Melanie by the GP practice after February 2025 despite Melanie describing suicidal ideation and suicidal thoughts. ▪ The request for Sertraline once a day given by a Consultant Psychiatrist to the Primary Care Network Mental Health Care Worker was not actioned by a GP working for Unity Healthcare.
4. Investigation and reflection Unity Healthcare wishes to express its deepest sympathies to the family and friends of Melanie Pinnell. Following this incident, we commissioned a comprehensive Patient Safety Incident Investigation (PSII) in accordance with the NHS Patient Safety Incident Response Framework (PSIRF). The investigation utilised system-based analytical tools, including the Systems Engineering Initiative for Patient Safety (SEIPS) and the Yorkshire
Suffolk GP Federation CIC Riverside Clinic, 2 Landseer Road, Ipswich, IP3 0AZ Tel: 0345 2413313 Email: info@suffolkfed.org.uk Web: www.suffolkfed.org.uk
Suffolk GP Federation CIC Registered in the UK. Registration number: 06183049 Registered address: Riverside Clinic, 2 Landseer Road, Ipswich, IP3 0AZ Reg. No: 1-140317426 Contributory Factors Framework (YCFF). We engaged openly with the Norfolk and Suffolk Foundation Trust (NSFT) and the Primary Care Network (PCN) to fully understand the systemic vulnerabilities that contributed to this outcome. The investigation concluded that the incident arose from a combination of interacting system factors rather than individual error. Specifically, the required protocol for prescribing queries (the "pink internal query hub slot") was bypassed in favour of an individual "task," making the clinical request invisible to the wider team. Furthermore, complex organisational boundaries between the Practice, PCN, and the Norfolk and Suffolk NHS Foundation Trust (NSFT) resulted in gaps in accountability for actioning specialist advice and a lack of systematic safety-netting for vulnerable patients.
5. Details of action taken or proposed Based on our PSII findings, we are implementing the following safety actions with specific oversight and timelines: Addressing Concern 1: Gaps in Follow-up and Safety-Netting ▪ Formal Caseload Reviews: We are introducing a formal caseload review between the practice and the Mental Health team to review plans and safety- net actions. This is owned by the PCN MH Service Lead and GP Clinical Lead for mental health. ▪ Managing Uncontactable Patients: We are standardising the process for managing uncontactable patients by developing and implementing a new Standard Operating Procedure (SOP). Addressing Concern 2: Un-actioned Prescription Requests and Task Limitations ▪ Removing Task-Based Prescribing: We are removing the use of the task system for prescribing requests entirely and developing an approved, formal pathway SOP. ▪ System Recording: To ensure visibility, all specialist advice will be recorded in both of our clinical systems, SystmOne and Lorenzo. ▪ Defining Ownership and Escalation: The PCN MH Clinical Lead and GP Clinical Lead for mental health are defining and re-enforcing clear ownership for prescribing actions and follow-up, as well as introducing a formal escalation SOP for incomplete actions.
Suffolk GP Federation CIC Riverside Clinic, 2 Landseer Road, Ipswich, IP3 0AZ Tel: 0345 2413313 Email: info@suffolkfed.org.uk Web: www.suffolkfed.org.uk
Suffolk GP Federation CIC Registered in the UK. Registration number: 06183049 Registered address: Riverside Clinic, 2 Landseer Road, Ipswich, IP3 0AZ Reg. No: 1-140317426 Outstanding Task Review System: A review system for outstanding tasks— specifically ensuring visibility of tasks assigned to locums, absent staff, or staff who have left the organisation—was implemented by Clinical Services Management in June
2025.
6. Shared learning To ensure wide-reaching impact, the findings and new SOPs will be presented internally at Unity Healthcare clinical meetings. Furthermore, an anonymised summary detailing the risks of task-based messaging for prescribing requests will be shared with the Suffolk and North East Essex Integrated Care Board (ICB) Quality Lead to promote shared learning across the wider system.
7. Statement of truth I believe the facts stated in this response are true to the best of my knowledge and belief.
Clinical Director, Unity Healthcare
Sent To
Response Status
Linked responses
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56-Day Deadline
21 May 2026
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
Report Sections
Investigation and Inquest
On the 3rd March 2026 I opened an Inquest into the death of Melanie Ruth Pinnell. She was
57. The Medical cause of death was given as: 1a) Hanging 2 Depression The conclusion was suicide contributed to on the balance of probabilities more than minimally by non-prescription of Sertraline 50mg once a day recommended by a psychiatrist approximately two months prior to her death, and absence of mental Health input following a mental health consultation approximately two months prior to her death.
57. The Medical cause of death was given as: 1a) Hanging 2 Depression The conclusion was suicide contributed to on the balance of probabilities more than minimally by non-prescription of Sertraline 50mg once a day recommended by a psychiatrist approximately two months prior to her death, and absence of mental Health input following a mental health consultation approximately two months prior to her death.
Circumstances of the Death
Melanie had a history of depression from at least 2004 Her mental health had recently deteriorated secondary to several social stressors She had a Consultation with a GP on 10/2/25 stating that: ‘Every so often she takes an 'emotional dive' can't stop crying, becomes paranoid that people are talking about her, feels suicidal. Has a couple of times had urges to act on her suicidal ideation. Struggles with anxiety all the time, low levels sensation of a knot in her stomach all the time.’ Melanie had a Consultation with a Primary Care Network (PCN) Mental Health Worker on 20/2/25: She described ‘feeling extremely low, feelings of despair, suicidal thoughts’ This Consultation was referred to the GP. No action was taken by the GP practice The PCN worker spoke to a Consultant Psychiatrist on 26/2/25 who recommended starting Sertraline 50mg once a day. The PCN Mental Health Worker tasked the GP to relay this to the patient. This was never carried out by the GP. There was no follow up arranged at the GP practice following these consultations until her death on 4th May 2025 when she was found hanging at home. She had left a final note.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths as detailed above, and I believe you or your organisation have the power to take any such action you identify.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.