Recurance · prevention of future deaths reports
Pre-inquest brief
Fragmented communication between mental and physical health services
The earlier warning
Kirsty Taylor · 28 Jul 2023 · Christopher Wilkinson, Hampshire, Portsmouth and Southampton
“there is and remains a fragmented relationship between mental health and physical health services, with little inter-service connectivity.”
judiciary.uk/…/kirsty-taylor-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Kirsty Taylor (28 Jul 2023) · stated timescale: 1 April 2024
“The creation of this new provider is progressing at pace (Project Fusion) with the new legal entity due to be in place by 1 April 2024.”
judiciary.uk/…/2023-0507-Response-from-Southern-Health-NHS-Foun…
What recurred
- 17 Nov 2025 · Ethel Robertson · Nicholas Walker · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Kirsty Taylor · 28 Jul 2023
“there is and remains a fragmented relationship between mental health and physical health services, with little inter-service connectivity.”
Later · Ethel Robertson · 17 Nov 2025
“If the presentation at the hospital was for a mental health related issue, then the OPMH team is likely notified as there will be contact with the psychiatric liaison service in the hospital.”
What happened next
No web check of the stated actions has been published for this chain.