The case of Kathleen Beardsmore is not unique.Official inquiries suggest repeated patterns elsewhere.

The review that did not happen

In 2015 NHS England ordered an independent review of deaths at Southern Health NHS Foundation Trust. It followed the death of an eighteen-year-old patient, Connor Sparrowhawk, and his family's refusal to accept the trust's account of it.

Over four years, 10,306 of the trust's patients died. The trust categorised 722 of those deaths as unexpected. It investigated 272 of them, and reported 195 as serious incidents.

Which deaths it investigated depended on the age of the patient. In adult mental health services the trust investigated three unexpected deaths in five. In older people's mental health services it investigated one in eight.

The older the patient, the less likely anyone looked.

Sources: The review · INQUEST's response

The letter the expert never saw

Within two weeks of Kathleen's death her husband wrote to the coroner's office. The letter set out his account of the afternoon before she died. It was date-stamped and received.Exhibit 03

The coroner appointed an independent doctor to report on Kathleen's care. He was sent the trust's statements. He was not sent the letter.

He concluded that the care had fallen below the standard expected but had not caused her death. The letter he was never sent described the point at which treatment could have started.

In June 2018 the Gosport Independent Panel reported on deaths at Gosport War Memorial Hospital. It found that relatives who raised concerns had been disregarded over a period of decades, and that it took the documents, recovered long afterwards, to establish what those relatives had been saying throughout.

Source: Gosport Independent Panel report

Records disclosed too late to use

In Kathleen's case her husband asked the Mount for the visitor records from its main reception in April 2019. The trust disclosed them days before the inquest opened in November, seven months later.Exhibit 14

They showed that he had signed out of the ward that evening. A nurse's statement to the coroner said that he had stayed.

There was no time to put the records to the witness.

Kathleen's family paid for their own barrister and solicitors. The trust's legal costs were met from public funds. INQUEST, the charity that works on deaths in state detention, reports that this disparity in funding is a feature of the system rather than an exception.

Source: INQUEST report

The law is being changed

The Public Office (Accountability) Bill is before Parliament. It is known as the Hillsborough Law.

It would place a legal duty of candour on public authorities and their staff when they deal with inquests and inquiries. It would make it an offence to fail that duty. It would give bereaved families legal representation on the same footing as the institutions they face.

Source: House of Commons Library briefing

The question the documents cannot answer

An inquest that finds death by natural causes ends the matter. An inquest that finds neglect does not.

In 2024/25 the NHS paid out £3.1 billion in compensation and associated costs for clinical negligence. At 31 March 2025 it had set aside £60.3 billion against the claims it expects still to face.

Source: NHS Resolution

Whether that has any bearing on how inquests are conducted is not something these documents can show.

If you have been through something similar

If you hold documents that record a comparable experience, you can get in touch.

Further reading

• INQUEST — Works with families after deaths in state detention, including deaths in mental health care.
• AvMA — Action against Medical Accidents. Advice and inquest support after medical harm.
• The Lampard Inquiry — Statutory inquiry into deaths in Essex mental health services. Continuing.
• Prevention of Future Deaths reports — The published database of reports made by coroners.
• Preventable Deaths Tracker — Research on those reports and the responses to them.
• Gosport Independent Panel — Report, June 2018.
• Public Office (Accountability) Bill — House of Commons Library briefing on the Hillsborough Law.