Lynsey Dearden: Prevention of future deaths report
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Date of report: 18/11/2025
Ref: 2025-0589
Deceased name: Lynsey Dearden
Coroner name: Emma Serrano
Coroner Area: Staffordshire and Stoke on Trent
Category: Suicide (from 2015)
This report is being sent to: NHS England | North Staffordshire Combined Healthcare NHS trust
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
 THIS REPORT IS BEING SENT TO:1. NHS England 2. North Staffordshire Combined Healthcare NHS Trust | |
| 1 | CORONER I am Emma Serrano, Area Coroner, for the coroner area of Staffordshire and Stoke on Trent. |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 3 | INVESTIGATION and INQUEST On the 12th March 2025, I commenced an investigation into the death of Mrs Lynsey Ellen Dearden. The investigation concluded at the end of the inquest on 18 November 2025. The conclusion of the inquest was a short form conclusion of suicide. The cause of death was: 1a) Asphyxiation 1b) [REDACTED] II) Anxiety and depression |
| 4 | CIRCUMSTANCES OF THE DEATH i) Mrs Dearden was found deceased, on the 11 March 2025, at her home address [REDACTED] |
| 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 1. Evidence emerged during the inquest that Mrs Dearden was allocated a Community Psychiatric Nurse, and key worker in November 2024 but had not received any appointments to the date of her death on the 11 March 2025. There was no real explanation as to why, or any policy or procedure to give a framework as to how or when appointments should take place; 2. Evidence emerged during the inquest that Mrs Dearden was allocated a Community Psychiatric Nurse, on the 31st December 2024, to facilitate a standard assessment framework, to assess what help and treatment Mrs Dearden may need in the community. This did not take place, and there was no answer as to when this should have taken place, or how this should have been carried out as there is no policy, guidance or framework in place to govern this. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 13 January 2026. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; 1. The family of Lynsey Dearden. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. |
| 9 | 18 November 2025 [REDACTED] Miss Emma Serrano Area Coroner Staffordshire |