Family call for independent investigation as coroner raises concerns with NHS Trust's mental health services after Wickham woman took her own life
A coroner has issued a Prevention of Future Deaths (PFD) report to a Hampshire NHS Trust after a woman took her own life having asked to be hospitalised - prompting her family to call for an independent investigation.
Samantha Young, 49, a teaching assistant from Wickham, was under the care of Hampshire and Isle of Wight Healthcare NHS Foundation Trust’s Community Mental Health Team (CMHT) when she died in November 2023.
She had made repeated pleas to be sectioned or admitted to hospital but a coroner found that staff failed to carry out suitable risk assessments or provide additional support to Samantha.
After a two-day inquest on June 5, 2025, HM assistant coroner Henry Charles said that Samantha had “done all she could to help herself and remain in the life of her daughter” by seeking metal health support.
Prior to her death, she had raised concerns with her GP who subsequently contacted the CMHT for help. She then spoke directly to her mental health nurse where she advised that she felt unsafe and needed to be hospitalised. In addition to this, she also reached out to a mental health text service where she expressed suicidal thoughts.
Following this, police conducted a welfare check at home with Samantha also calling NHS 111. The details of the call were shared with the CMHT.
The inquest heard how the CMHT failed to carry out appropriate risk assessments, did not escalate Samantha’s case, and offered no additional support. She was left without adequate crisis care and was instead provided with an out-of-hours telephone line which was not answered on several occasions - a court heard.
Despite Samantha consenting to the mental health team sharing details of her mental health with her family, the CMHT did not contact her family to tell them about her condition or ask for their input on how best to support her.
A Prevention of Future Deaths (PFD) report by HM assistant coroner Henry Charles said: “In my opinion there is a risk that future deaths could occur unless action is taken.”
The report highlighted a a lack of mental health assessment training for agency staff used by the Trust and the lack of engagement that the CMHT has with families of those in their care. It said Hampshire and Isle of Wight Healthcare NHS Trust should review its provision of training for agency staff, in particular in respect of risk assessments.
It is not the first time a PFD report has been sent to the Trust, with one raising similar concerns sent to it four months prior to Samantha’s death.
The PFD following the inquest into Samantha’s death quoted concerns raised by the senior coroner in a previous PFD report and said Hampshire and Isle of Wight Healthcare NHS Trust should review guidelines and procedures concerning communication with family and friends of patients with mental health difficulties by its permanent and agency staff, and monitoring of whether such communication has taken place.
Samantha's family believe these failings “effectively assisted in the death of our sister” and have called for a independent investigation.
A statement released through their lawyers at Leigh Day said: “We believe the trust’s mental health team effectively assisted in the death of our sister. In the last 10 days of her life, unknown to the family, Sammy self-rescued by calling emergency and mental health services three times.
“She begged them to take her into hospital; to keep her safe and protect her daughter from her own painful experience of losing a parent to suicide. Three times members of the CMHT refused Sammy’s pleas for help and did not remove the means of suicide. This was after years of failing to offer Sammy treatment.
“Sammy’s death is in a long list of cases in which desperately ill mental health patients have been denied their right to treatment by NHS mental health services. This needs an independent investigation. Without the NHS being held to account for their failings more people will die.”
Julia Reynolds, a partner in the clinical negligence team at law firm Leigh Day, is representing the family. She said: “This has been an exceptionally distressing case. Samantha was a much-loved and devoted mum to her daughter who should have received the support she was crying out for. It is quite remarkable the lengths that Samantha had gone to seek help. But that help was simply not provided.
“The inquest into her death found that she was badly let down by mental health services, to whom she repeatedly expressed her need for help. Her situation should have been escalated, and her family should have been informed.
“It is a matter of grave concern that this is not the first time a family has lost a loved one due to mental health struggles where a coroner has had to make a Prevention of Future Deaths report about this Trust.
“I sincerely hope that this tragic case results in improvements in the mental health support provided by Hampshire and Isle of Wight Healthcare NHS Foundation Trust so that another family does not have to endure the heartbreak that Samantha’s family has.”
The Trust have advised they have carried out a full investigation and are “profoundly sorry”.
Susanna Preedy, Clinical Director for Mid and North Division, Hampshire and Isle of Wight Healthcare NHS Foundation Trust said:
“We are deeply saddened by Sammy’s death and our thoughts are with her family and friends.
“Following this incident, we carried out a full investigation and have identified where our care fell short, for which we are profoundly sorry. We fully accept the findings of the coroner and are committed to doing everything we can to put in place the necessary changes to prevent anything similar happening again.
“This includes clearer risk assessment processes, stronger follow-up procedures and better involvement of families and carers.”
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