Sunny Eymond
6 May 2026 · Coroner Simon Burge · Hampshire, Portsmouth Southampton
The coroner's concerns
1. lack of national action on lessons learned
“While the two trusts involved in the inquest (Southern Health and Avon & Wiltshire Mental Health Partnership NHS Trust) have undertaken reviews, learned lessons and implemented changes following [the deceased]'s death, the same has not happened at a national level/England wide Trust level”
2. risk of death from unaddressed transfer concerns
“Firstly, I am concerned that a risk of death may arise in the future if the concerns raised are not addressed more widely and brought to the attention of other Trusts and consideration is not given to the production of national guidance on cross Trust transfer of complex cases, particularly those involving patients with a diagnosis of an eating disorder and complex Post Traumatic Stress Disorder/Emotionally Unstable Personality Disorder/complex emotional needs”
3. absence of national transfer guidance
“There is currently no national guidance on how best to manage and plan for Trust to Trust transfers of highly complex cases (in particular those involving patients with both a diagnosed eating disorder such as AN and complex emotional needs)”
4. lack of national treatment pathway
“There is currently no national specified treatment pathway for individuals who present with co-existing eating difficulties and complex emotional needs”