22 September 2023

Before HM Acting Area Coroner Catherine Wood
Maidstone Coroner’s Court
5-9 June 2023

A coroner has raised her concerns to the Health Secretary about the risk of future deaths due to inadequate staffing on NHS wards, a lack of trained staff and difficulties in recruiting trained nurses.

On 22 August 2022 June Angela Challis (known to her family and friends as “Angie”) died following an incident where she had swallowed an item on the mental health ward where she was detained at the time. An inquest into her death concluded that:

  •  There was insufficient information provided to staff to ensure adequate care.
  • Angie was not sufficiently observed due to lack of staff.
  • There was a failure of acceptable support in relation to discharge anxiety.
  • Defective assessment and documentation of risk-assessment relating to Angie’s risk of self-harm and triggers for exacerbation of her mental health.

Kent and Medway NHS Trust admitted to failures with regard to observations, risk assessment and recognise that there was insufficient staffing levels available at the time of Angie’s death.

The coroner has now issued a Prevention of Future Death (PFD) report.  A coroner can make a PFD report following an Inquest where they are concerned that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, and in the Coroner’s opinion action should be taken to prevent the occurrence of continuation of such circumstances, or to eliminate or reduce the risk of death.

The PFD has been sent to the Health Secretary as well as the Chief Executive of NHS England. Within the coroner’s report she has expressed her opinion that action should be taken to prevent future deaths, particularly in relation to the following three issues:

1. Insufficient staff

In Angie’s Inquest it was revealed that there were insufficient staff on the ward, with at times only one qualified member of staff being on duty not two was the complement for the ward. It was noted that there were also some issues with non-qualified staff shortages but the main difficulty was with the Trust’s ability to provide adequately trained staff to fill the shifts needed. 

It was heard in evidence that when only one member of qualified staff was on duty, they were required to prioritise different clinical demands and the safety of patients was compromised. 

Angie was showing signs of distress on 18 August, but the member of staff had to consider the needs of all patients on the ward.  Had another trained member of staff been on duty they may have been able to assist and/or observe Angie more closely.  The jury at Angie’s Inquest found that Angie was not sufficiently observed due to lack of staff. 

2. Inadequate risk assessment

The jury also concluded that there was defective assessment and documentation of risk-assessment relating to Angie’s risk of self-harm and triggers for exacerbation of her mental health.  The coroner has raised her concern that inadequate assessment of risk may also have been due to a lack of trained staff on the ward and a lack of time to consider and update any individual patient’s risk assessments. 

3. Number of qualified staff members

Since Angie’s death, Kent & Medway NHS Mental Health Partnership provided evidence that significant local steps have been taken to reduce the risks to patients and recruitment is ongoing but the evidence heard indicated that the Trust have real difficulties recruiting to posts and considered that in part this was due to a reduction in the numbers of nurses training. 

In evidence at the Inquest, Kent & Medway NHS Trust commented on the impact that removal of the bursary for nursing training had on trained nurses coming through.  As trainee nurses are no longer able to receive the training bursary they need to fund it themselves. The Trust informed the Court that they have seen a drop in qualified nurses coming through. 

The coroner has requested a response from the Health Secretary and Chief Executive to her concerns by 4 October.  The response must contain details of action taken or proposed to be taken, setting out a timetable for action. Otherwise, there must be an explanation provided why no action is proposed.  

Similar concerns have been raised by other coroners around staff shortages and the contribution this has towards patients losing their lives.

Carly McNamara, Angie’s daughter said: Both myself and my sister Jade miss our Mum so much and her beautiful smile. During our childhood she always provided us with the care and support we needed. Our Mum always made us laugh and was always singing.  She loved those around her endlessly. She had such a strong relationship with her grandson.

We were distressed to discover that despite numerous swallowing incidents that my mum had not been risk assessed or placed upon the appropriate level of observations. We share concerns about how inadequate staffing and a lack of trained staff on the wards impacted the quality of our Mum’s care. We really do hope that changes are made so that no other family experiences the devastating pain and loss suffered by our family.”


Leanne Devine of Scott Moncrieff Solicitors said: "The NHS is operating with significant shortages of staff. It was reported earlier this year that staff shortages in England could exceed 570,000 by 2036. 

Angie’s death is one example demonstrating the tragic and real consequences of an under resourced National Health Service. This isn’t just about numbers of staff, the concern is also about ensuring that we have sufficiently trained staff members in our hospitals. If action isn’t taken to address this issue it will only deteriorate further and sadly there will be more deaths. Action must be taken now to address this situation and I hope the Health Secretary takes on board the concerns raised by the coroner.”



For further information, interview requests and to note your interest, please contact Lucy McKay on 020 7263 1111 or [email protected]

The family is represented by INQUEST Lawyers Group members Leanne Devine, Human Rights Lawyer and Consultant Solicitor at Scott Moncrieff Solicitors and Counsel Angelina Nicolaou of One Pump Court Chambers.

The family are supported by INQUEST caseworker Caroline Finney.

Other Interested persons represented are Kent and Medway NHS Mental Health & Social Care Partnership NHS Trust.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.