Lynsey Dearden

I am Emma Serrano, Area Coroner, for the coroner area of Staffordshire and Stoke on Trent.

On the 12 th 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

i)    Mrs Dearden was found deceased, on the 11 March 2025, at her home address [REDACTED]

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  31

st 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.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.