Naomi Aylott
29 Sept 2025 · Coroner Robert Simpson · Hampshire, Portsmouth and Southampton
The coroner's concerns
1. lack of face to face contact with care coordinator
“I am concerned that [the deceased] was never seen face to face by her care co- ordinator over the 3 - 4 month period that she was under the care of the CMHT”
2. inadequate risk assessment training and compliance auditing
“I am concerned that within the Andover CMHT the training around risk assessments and the auditing of compliance with risk assessment policy is not adequate”
3. exclusion of family from care discussions
“I am concerned that the Andover CMHT do not appear to have considered how to keep a person's family involved in their care (when there is the appropriate consent to do so) when meetings with the care co-ordinator take place over the phone and not face to face”