Sophie Towle
24 Oct 2025 · Coroner Alexandra Poutney · Nottingham and Nottinghamshire
This report repeats 3 earlier warnings. See the linked reports.
The coroner's concerns
1. foreign body insertion
“Lack of joint agency policy/cross-sector working between physical and mental health trusts in relation to the insertion of foreign bodies”
2. VTE risk assessment
“lack of clarity in relation to the current local VTE policy”
3. specialised personality disorder service
“disbanding of the Personality Disorder Hub at NHCT”
4. foreign object management policy
“policy and procedures around the management of insertion of foreign objects for SFH”
5. insufficient staffing
“staffing levels on Fir Ward both at the time of [the deceased]'s admission, and now, are insufficient”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“The court heard evidence that there is no national therapeutic pathway for | treatment of Personality Disorders”
This report
“I am told that as of mid-October 2025, the Personality Disorder Hub at NHCT has been disbanded.”
Closely relatedConfidence 0.90 · high
Earlier report
“At no time during the two periods of Ms [name redacted] inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of trust policy.”
This report
“During the course of [the deceased]'s inquest, I heard evidence which concerns me that there is a lack of clarity in relation to the current local VTE policy.”
Closely relatedConfidence 0.90 · high
Earlier report
“A lack of robust policy relating to Ingestion of Foreign Bodies I heard evidence that the Trust is in the process of drafting a policy, but it became clear during evidence that the policy is not yet sufficiently robust.”
This report
“I have had sight of the newly ratified local policy for management of insertion of foreign objects at SFH. I am concerned that its content is lacking in specificity, the language used is vague and open to interpretation, and it does not provide clear advice for medical professionals accessing it for guidance.”
Responses
2025-0552-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action · 2027
“ICBs are currently delivering their 3-year strategic plan for commissioning mental health inpatient services. The plans will realise the aims set out in the NHS Mental Health Inpatient Commissioning Framework (NHS England 2024). This Framework is a national guide for how Integrated Care Boards (ICBs) plan inpatient mental health services. It sets out what”
2025-0552-Response-from-Nottingham-Healthcare-NHS-Foundation-Trust-.pdf ↗· Nottinghamshire Healthcare NHS Foundation Trust
2025-0552-Response-from-Sherwood-Forest-Hospitals-NHS-Foundation-Trust-.pdf ↗· Sherwood Forest Hospitals NHS Foundation Trust