Trust’s missing training contributed to death

A coroner has warned a trust over communication failures, leadership and a “lack of professional curiosity” in relation to a patient’s death, which appear to echo previous cases at the provider.

Hampshire and Isle of Wight Healthcare Foundation Trust was criticised by area coroner Nicholas Walker after the death of 34-year-old Abigail Jelley, who took her own life last year while suffering from post-natal depression.

Mr Walker said he was concerned “structural issues with the leadership of [the trust]” could result in harm done to future patients.

He referred to an internal investigation report that he said described a “lack of professional curiosity, lack of escalations of deteriorating patients, non-patient centred decision making and a linear approach to risk assessment and formulation”.

The coroner described how Ms Jelley, who began to struggle with her mental health after the birth of her second child in 2024, was seen by different mental health professionals “whose job it was to react to that crisis and attempt to assist her through it”.

Ms Jelley had been living with her parents before she died, who could have provided valuable information, but they were not spoken to by medical professionals, the coroner said. 

He noted: “It was accepted [by the trust] that there was a lack of professional curiosity shown by professionals both in Abigail’s case and generally.”

It was also found that community mental health teams do not receive mandatory training on perinatal “red flags”, and despite requesting it longer than a year ago, the team had yet to receive it. 

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Source: HSJ, 5 November 2025