Jacqueline Potter
24 Apr 2025 · Coroner Samantha Marsh · Somerset
The coroner's concerns
1. lack of codified risk and safety planning for first overnight leave
“[name redacted] was not sent home for her first overnight leave with any codified 'Risk' and 'Safety Planning' document”
2. unrestricted access to self-harm websites by vulnerable in-patients
“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”
3. insufficient menopausal care for women in NHS
“lack of 'importance' given to menopausal care available to women on the NHS”
Responses
2025-0200-Response-from-NHS-England.pdf ↗· NHS England
Stated action · 2024
“In 2024, NHS England published specific Menopause Educational resources to enhance learning for practice nurses.”
2025-0200-Response-from-NICE.pdf ↗· Royal College of General Practitioners
Stated action
“We have outlined the concerns below, detailing NICE's response to each in turn.”
2025-0200-Response-from-RCOG.pdf ↗· Royal College of Obstetricians and Gynaecologists
2025-0200-Response-from-Somerset-NHS-Foundation-Trust.pdf ↗· Somerset NHS Foundation Trust
2025-0324-Response-from-Kenny-Murphy-Ltd.pdf ↗· Somerset NHS Foundation Trust
Stated action
“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”