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Amy Pugh

1 Dec 2025 · Coroner Paul Marks · East Riding and Hull
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The coroner's concerns

  1. 1. inability to access mental health records

    “Following [the deceased]'s admission to Avondale Unit on 8th April 2024, clinical staff were unable to access important records pertaining to [the deceased]'s mental health from partner NHS mental health institutions and this compromised her assessment and subsequent management.”

Responses

2026-0013-Response-from-NHS-England.pdf ↗

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Amy Pugh · Recurance