Failure by NHS Trust to prioritise family involvement in crisis care plan played a part in mother’s suicide.

Dean Wilson have recently acted in an Inquest earlier this month, touching upon the death of Joanna Chamberlain. Dean Wilson were instructed by Joanna’s husband ahead of the Inquest that was held on 7 November 2025 at Woodvale Coroner’s Court, in Brighton. Dean Wilson continue to act for Joanna’s husband to pursue a civil claim following the findings of the Inquest. 

Joanna Chamberlain was born on 15 December 1981. She lived with her husband, and teenage son in Hassocks, West Sussex. Joanna was an incredibly empathetic person, who did everything she could to help others and had roles as a Healthcare Assistant, end-of life carer, and in special education. 

On 23 January 2025, Joanna sadly took her own life at home. Joanna had made multiple attempts on her life in the months leading up to her death. At the time of her death, Joanna was under the care of Sussex Partnership NHS Foundation Trust (SPFT), via Linwood ATS and subsequently the Crisis Resolution Home Treatment Team (CRHTT). 

Background 

Joanna had an incredibly close relationship with her 3 siblings. During Joanna’s childhood she experienced abuse and neglect and was put into care at 14 years old. She had a long history of mental health issues but, found her feet again once she met her husband when she was 23 years old. 

Joanna had a complex mix of both physical and mental health conditions. She had been diagnosed with ADHD, Autism and PTSD, as well as Anxiety and Depression. Joanna had gone into early menopause and started HRT treatment as prescribed by her GP and her mental health declined towards the end of 2024. In the subsequent months, Joanna made multiple attempts to end her life. 

The day before her death, Joanna had attended clifftops near her home with the intention of jumping. She decided against this when considering the impact this would have on her son. Joanna subsequently called her GP to inform her of this and express her concerns for her own safety.  The GP contacted Linwood ATS to relay this information ahead of her scheduled appointment later that day. 

At 1pm, Joanna had an appointment with a locum clinical psychiatrist at Linwood ATS, during which she was assessed as being at moderate risk. The assessment was reached largely based on Joanna’s immediate presentation and referral to care notes but, no other third party or family input was considered.

The Triangle of Care 

Sussex Partnership NHS Foundation Trust are members of the Triangle of Care run by the Carers Trust. They have been members since 2017. This is based on 6 key standards and focuses on keeping carers included, informed and supported when they are caring for an individual with mental health difficulties. The triangle is made up of the clinician, the patient and the carer (this can be family). 

Throughout Joanna’s care, the Trust failed to seek or receive input from Joanna’s family despite Joanna’s repeated reference to her husband and son being protective factors. Joanna had withdrawn consent for her confidentiality to be waived in regard to her husband, , two days before her death. Even before this was withdrawn, her husband had not at any time been consulted or included in her care plan. He was not aware he could provide information to the Trust at any point. 

The Havens 

The Haven’s are dedicated mental health crisis assessment facilities across Brighton, Hove, East Sussex and West Sussex. They provide 24-hour mental health crisis facilities and are an alternative to attending A&E or a hospital admission for individuals experiencing a mental health crisis. The Havens are made up of 5 locations in total. 

At the beginning of Joanna’s assessment, a call was made to see if there would be a bed available for Joanna at either Mill View Hospital in Hove, or Langley Green Hospital in Crawley. There was no availability at either location. Despite this call, the clinical psychiatrist who assessed Joanna was of the view that she was not acutely suicidal and a 24-hour period at a Haven crisis facility was not considered necessary at this stage.

Crisis Resolution and Home Treatment Team (CRHTT) 

After the assessment, it was agreed Joanna’s care would be escalated to the CRHTT and a home assessment was scheduled for the 23 January 2025 at 10am. 

Joanna’s husband did not receive a response from Joanna to his calls or texts on the morning of the 23 January 2025. Matthew raised the alarm with the Trust considering Joanna’s scheduled appointment and with his family. He was concerned about Joanna and made the decision to promptly leave work and drive back to their home address. Sadly, Joanna had taken her own life and was found deceased by her husband upon his return home. The appointment with the Crisis Team never went ahead as Joanna had taken her own life before they’d attended. Emergency services attended the scene despite the police and paramedics attempts to perform CPR, Joanna was pronounced dead at 13:16pm. 

Internal Investigation 

A Patient Safety Incident Investigation (PSII) Report was prepared by SPFT on 1 August 2025, where it was recognised that there are areas for improvement within the Trust. 

Following the finalisation of the internal investigation, George Chapman, Associate Director of Suicide Prevention within SPFT made 5 recommendations as part of an ongoing action plan for the Trust following Joanna’s death. 

The first to confirm whether there are currently any projects that are ongoing within the Trust relating to family engagement in registration authority (RA) and safety planning. Secondly, to establish a working group to respond to identified gaps using a quality improvement approach. 

Thirdly, to focus on the implementation of local QI projects and the fourth, to conduct a review of their Electronic Patient Record (EPR) system in light of quality improvement outputs. Finally, it recognised the need for training, planning and implementation for best practice based on the quality improvement outputs.  

Whilst the PSII report highlighted areas where the Trust’s processes and systems were lacking when prioritising family involvement, the answers it provided were largely insufficient. It failed to recognise that not referring Joanna to an inpatient mental health facility was a missed opportunity to protect Joanna from harm. The fact that there were no beds available at 2 out of the 5 Haven facilities highlights the shortage of mental health resources in the area. This poses a significant risk to individuals going through a mental health crisis like Joanna. There are clearly gaps in the system and it is concerning to see that individuals appear to be at risk of ‘falling through the cracks’ if they are not deemed at a high enough risk to warrant an inpatient stay at one of the Havens.  Joanna’s case also demonstrates there are clear improvements that can be made to target the capacity issues across the facilities in the area. 

Inquest  

Dean Wilson Solicitors were instructed by Joanna’s husband in March of this year. Support and advice were provided to Joanna’s family throughout the coronial process leading up to the Inquest. Dean Wilson worked hard to ensure that the failures of SPFT were brought to the coroner’s attention and that the relevant witnesses were called to provide live evidence in order to obtain as many answers for the family as possible. 

The Inquest was later held on 7 November 2025 at Woodvale Coroner’s Court in Brighton. Joanna’s family were assisted by Ben Davey and Summer Woodman of Dean Wilson Solicitors, who instructed Robert Horner of Deka Chambers to represent Joanna’s husband and family at the Inquest. 

After hearing evidence from both parties, the coroner concluded that ‘Joanna had experienced suicidal thoughts for many months and had made several previous attempts but, had not been assessed as high risk, in part because no input was sought or received from her family.’ 

The coroner has since prepared a Regulation 28 Prevention of Future Deaths Report, which covers matters of concern brought to the coroner’s attention following the conclusion of the inquest. Mr Turner states ‘there appears to be a local and national gap between the provision of safe and supportive spaces, where clinical help and care can be given to mental health patients who may not be in immediate crisis, yet who would benefit from more support than can be given by home treatment plans. He goes on to say this also applies to those ‘whose risk assessment suggests they may benefit when protective factors change or are temporarily unavailable at certain times of the day or night.’ 

It is the coroner’s determination that actions should be taken by the Trust to prevent future deaths. 

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Please visit our inquest page or contact us today at 01273 249200 if you would like to speak to someone in our team. If you or someone close to you is struggling with their mental health and need someone to talk to, call Samaritans for free at 116 123 or visit Samaritans.org.