Recurring concern

Failure to recognise and provide joined-up care for menopause-related deterioration

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First reported 22 Feb 2021•Latest report 24 Apr 2025

Definition

What this concern includes

Includes deficiencies in the end-to-end provision of menopause care, including access to appropriately skilled practitioners and dedicated clinical coordination or consideration of menopause-related factors in care for women.

Not included

Excludes generic failures in primary-secondary care coordination unless they are explicitly tied to menopause care.
Excludes deficiencies concerning mental-health assessment or treatment that do not explicitly concern menopause or perimenopause.
Excludes generic workforce, training, guidance or documentation deficiencies without an explicit menopause-care connection.

Reports: 4
Individual concerns: 10
Date range: 2021–2025
Stated actions: 24

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

National Institute for Health and Care Excellence3

NHS England2

Somerset NHS Foundation Trust2

Department of Health and Social Care1

General Medical Council1

Hampshire and Isle of Wight Healthcare NHS Foundation Trust1

Royal College of General Practitioners1

Royal College of Obstetricians and Gynaecologists1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

24 Apr2025
Somerset
Concerns raised3
1. Insufficient availability of specialist menopausal practitioners in primary and Trust-wide care
2. Lack of mandatory menopausal training for relevant clinical practitioners
3. Failure to recognise the clinical importance of menopausal symptoms and care
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 14
1. Action
  Work with regions and Integrated Care Boards to improve nationwide access to good menopause care.
  Stated by NHS EnglandStated in progress
2. Action
  Embed menopause management in the obstetrics and gynaecology training curriculum and MRCOG examination syllabus.
  Stated by Royal College of Obstetricians and GynaecologistsStated completed
3. Action
  Provide a Special Interest Training Module covering assessment, investigation and treatment counselling for menopause-related symptoms.
  Stated by Royal College of Obstetricians and GynaecologistsStated completed
1. Action
  Include menopause diagnosis, investigation and management in the DRCOG examination syllabus for interested general practitioners.
  Stated by Royal College of Obstetricians and GynaecologistsStated completed
2. Action
  Host recurring menopause-related training and education events accessible to healthcare professionals.
  Stated by Royal College of Obstetricians and GynaecologistsStated completed
3. Action
  Provide menopause-related education and training for mental health and wider Trust colleagues, including what to identify, consider and where to signpost.
  Stated by Somerset NHS Foundation TrustStated in progress
4. Action
  Publish menopause educational resources to enhance practice nurses’ learning.
  Stated by NHS EnglandStated completed
5. Action
  Develop menopause workforce support packages and tools, including decision support and self-care resources.
  Stated by NHS EnglandStated in progress
6. Action
  Launch menopause awareness sessions and related e-learning packages for healthcare and people professionals.
  Stated by NHS EnglandStated completed
7. Action
  Improve clinicians’ assessment of menopause-related mental health presentations through an ongoing task-and-finish group and structured consideration of relevant symptoms and history.
  Stated by Somerset NHS Foundation TrustStated in progress
8. Action
  Add an electronic patient-record prompt in Dialog+ to support consideration of menopause in eligible patients.
  Stated by Somerset NHS Foundation TrustStated completed
9. Action
  Develop a toolkit supporting menopause information events and group consultations in local areas.
  Stated by NHS EnglandStated in progress
10. Action
  Promote high-quality and equitable menopause care coverage for all.
  Stated by NHS EnglandStated in progress
11. Action
  Update menopause and mental health guidance following surveillance of relevant evidence and recommendations.
  Stated by National Institute for Health and Care ExcellenceStated completed
Respondent positions 7
1. Position
  NHS England and the Royal Colleges are better placed to address the lack of NHS menopause specialists and services.
  Stated by National Institute for Health and Care ExcellenceRedirects responsibility
1. Position
  NHS England and the Royal Colleges are better placed to address the lack of specialist menopausal care and GP upskilling.
  Stated by National Institute for Health and Care ExcellenceRedirects responsibility
2. Position
  Employing organisations determine locally mandated menopause training according to their priorities and patient needs.
  Stated by NHS EnglandRedirects responsibility
3. Position
  Professions and royal colleges determine profession- or role-specific menopause training standards and curricula.
  Stated by NHS EnglandRedirects responsibility
4. Position
  Setting undergraduate and trainee doctors’ curricula, including compulsory menopause training, is outside NICE’s responsibility.
  Stated by National Institute for Health and Care ExcellenceOutside remit
5. Position
  The General Medical Council and Health Education England are responsible for considering menopause training curricula.
  Stated by National Institute for Health and Care ExcellenceRedirects responsibility
6. Position
  NICE considers its updated menopause and mental health guidelines up to date and continues surveillance of relevant studies.
  Stated by National Institute for Health and Care ExcellenceExisting arrangements considered sufficient
AI-generated summary

Jacqueline Anne Potter · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Jacqueline Anne Potter, known as Anne, died on 5 December 2022 after taking a car and deliberately driving into the path of an HGV tanker on the A303 during overnight leave from a psychiatric unit. The report raises concerns about families not receiving a codified risk and safety planning document for a patient’s first overnight leave, unrestricted access to self-harm websites through secure unit Wi-Fi, and inadequate recognition and provision of menopausal care and training.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient availability of specialist menopausal practitioners in primary and Trust-wide care
Wider context from the report
“(ii) I was told that the Trust has just one ‘menopause specialist’ (a GP) who covers the entire Trust operations. Not all GP surgeries have a menopause specialist practitioner (or access to one) despite a GP usually being the first port of call for women in the community when seeking primary care. Those GP Surgeries who do have a practitioner who acts as a ‘specialist’ is often a GP with a personal interest who has taken the initiative to go on courses and broaden their learning and understanding, rather than any mandatory requirement for a Surgery [or group with multiple surgeries] to have an available community ‘front-line’ specialist. I was told that the Trust does not have an “expert” in this field and it would be difficult to have one as menopause isn’t a disease or an illness. Whilst I do not dispute that is it not a disease, menopause is a condition; it does have symptoms and it does have recognised presentations, yet there appears to be a failure to recognise this condition as having equal importance to other ailments or diagnoses. ”
Source location
Jacqueline Anne Potter · Prevention of Future Deaths report
Page 5 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of mandatory menopausal training for relevant clinical practitioners
Wider context from the report
“(i) Certain elements of medicine and clinical practice training are compulsory but having heard evidence at the Inquest around mandatory and statutory training modules I learnt that this covers areas such as GDPR training and disposal of sharp objects such as syringes. I was surprised to learn that menopausal training is not mandatory in any area of clinical practice or specialism. I am concerned that there is no requirement to undertake essential compulsory menopausal training for those working in ‘relevant’ clinical practices such as Mental Health Practice, Obstetrics and Gynaecology and Oncology, or even general as a general GP. ”
Source location
Jacqueline Anne Potter · Prevention of Future Deaths report
Page 5 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to recognise the clinical importance of menopausal symptoms and care
Wider context from the report
“I was told during a previous PFD Response relating to menopausal knowledge and care within the NHS that “It is important to ensure that women understand common symptoms such as anxiety, stress and depression which they might experience during the menopause and where and when to seek help. The NHS website has resources….” This emphasises my concerns entirely; the lack of importance given to menopausal symptoms. If someone has concerns about heart disease, a worrying lump, a broken bone etc they expect to be able to consult a medically qualified professional who has a knowledge and understanding of their condition or presentation and can diagnose and treat accordingly; not just [and I paraphrase] ‘have a look at a website to help’. I appreciate that each and every woman will experience perimenopause and menopause differently, their individual experience is unique to them and this, to some degree, creates difficulties as a ‘one size fits all’ approach (which is perhaps achievable in other medical specialisms and disciplines) cannot be offered, but the lack of recognition of the importance of this condition remains a significant concern. I had previously been told (back in a 2024 PFD response) of a roll-out of specialist menopausal care and upskilling of GPs but there was little evidence during the inquest that this has happened/is happening and women continue to approach and navigate the menopause without the support of expert clinicians or practitioners who understand and can treat the symptoms they are experiencing. ”
Source location
Jacqueline Anne Potter · Prevention of Future Deaths report
Page 5 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Work with regions and Integrated Care Boards to improve nationwide access to good menopause care.

Verbatim wording from the response
“There is often variation between GPs and practices in the level of complexity of care they are able to provide. Women’s Health Hubs were piloted in 2023/2024, seeking to reduce the variations in reproductive healthcare which women reported receiving. They provide the option for women to be referred to more specialist reproductive health care (including menopause care) if the GP needs further advice. Women’s Health Hubs have yet to achieve full coverage, but have the potential to fill the gap in care where this is more complex. NHS England is working closely with its regions and Integrated Care Boards (ICBs) to ensure that every woman can access good menopause care wherever they are in the country.”

Source location
Response from NHS England
Page 2 · response
Published 25 April 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Embed menopause management in the obstetrics and gynaecology training curriculum and MRCOG examination syllabus.

Verbatim wording from the response
“To support doctors in this aim, the RCOG provides educational initiatives, including its curricula on which the MRCOG qualification is based and tested through examinations, elevating care standards through clinical guidance, assisting in career advancement through examinations, coordinating professional development initiatives and events, and offering support services to its members.”

Source location
Response from RCOG
Page 2 · response
Published 25 April 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide a Special Interest Training Module covering assessment, investigation and treatment counselling for menopause-related symptoms.

Verbatim wording from the response
“The College also has a Special Interest Training Module (SITM) in menopause care. This SITM is aimed at learners with an interest in menopause care. It provides training on how to assess and investigate women with menopause-related symptoms, understand the benefits and risks of HRT and alternative therapies, and counsel and advise women accordingly.”

Source location
Response from RCOG
Page 2 · response
Published 25 April 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Include menopause diagnosis, investigation and management in the DRCOG examination syllabus for interested general practitioners.

Verbatim wording from the response
“Additionally, for General Practitioners who would like to develop a more advanced knowledge of women’s healthcare, the RCOG also provides the Diploma of the Royal College of Obstetricians and Gynaecologists (DRCOG). The core syllabus for this examination also includes diagnosis, investigation and management of the menopause. The DRCOG is primarily undertaken by those in General Practice who have an interest in Women’s Health but is not mandatory.”

Source location
Response from RCOG
Page 2 · response
Published 25 April 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Host recurring menopause-related training and education events accessible to healthcare professionals.

Verbatim wording from the response
“Throughout the course of each year the RCOG and our Specialist Society (British Menopause Society) also host numerous training and education events which are accessible to all healthcare professionals, several of which support additional education into various aspects of care for menopausal women.”

Source location
Response from RCOG
Page 2 · response
Published 25 April 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide menopause-related education and training for mental health and wider Trust colleagues, including what to identify, consider and where to signpost.

Verbatim wording from the response
“There is an ongoing task and finish group which is leading on this piece of work and has focused on improving clinicians understanding of what to look for, ask about and consider when assessing patient who may fit in this category. If there is a potential consideration, we add a prompt to our electronic patient record, Dialog+, to ask these questions. Whilst it is not expected that mental health clinicians will make a primary diagnosis of menopause we expect it to be on the list of considerations of patients who meet the criteria. For the clinician there must be consideration of what Mental Health and menopausal symptoms might look like, with an awareness of potential for overshadowing, and the need to establish a proper history from the patient. This is supported by the training offered by the Royal College of Psychiatrists and internal training.”

Source location
Response from Somerset NHS Foundation Trust
Page 2 · response
Published 25 April 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Publish menopause educational resources to enhance practice nurses’ learning.

Verbatim wording from the response
“Practice nurses also have a significant role in menopause care and are often the first port of call for some women experiencing difficulties, or who may have the opportunity to proactively enquire about the menopause. In 2024, NHS England published specific”

Source location
Response from NHS England
Page 1 · response
Published 25 April 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop menopause workforce support packages and tools, including decision support and self-care resources.

Verbatim wording from the response
“A toolkit that supports local areas to provide menopause information events and group consultations is under development to improve access and also to provide a forum for learning for other healthcare professionals. NHS England is working on menopause workforce support packages for employees and employers and developing a range of tools to upskill, including two e-learning packages (Menopause Awareness – e-learning for healthcare and Menopause and people professionals eLearning for healthcare), decision support tools and a self-care factsheet to empower women to understand and self-manage their perimenopause and menopause symptoms, and to point them towards further sources of credible information.”

Source location
Response from NHS England
Page 2 · response
Published 25 April 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Launch menopause awareness sessions and related e-learning packages for healthcare and people professionals.

Verbatim wording from the response
“In recent years, the NHS England National Menopause programme has also launched a series of awareness sessions, including the ‘Menopause awareness’ and ‘Menopause and people professionals’ e-learning packages referenced earlier on in this response, as well as e-learning on ‘Menopause and occupational health’.”

Source location
Response from NHS England
Page 4 · response
Published 25 April 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Improve clinicians’ assessment of menopause-related mental health presentations through an ongoing task-and-finish group and structured consideration of relevant symptoms and history.

Verbatim wording from the response
“There is an ongoing task and finish group which is leading on this piece of work and has focused on improving clinicians understanding of what to look for, ask about and consider when assessing patient who may fit in this category. If there is a potential consideration, we add a prompt to our electronic patient record, Dialog+, to ask these questions. Whilst it is not expected that mental health clinicians will make a primary diagnosis of menopause we expect it to be on the list of considerations of patients who meet the criteria. For the clinician there must be consideration of what Mental Health and menopausal symptoms might look like, with an awareness of potential for overshadowing, and the need to establish a proper history from the patient. This is supported by the training offered by the Royal College of Psychiatrists and internal training.”

Source location
Response from Somerset NHS Foundation Trust
Page 2 · response
Published 25 April 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Add an electronic patient-record prompt in Dialog+ to support consideration of menopause in eligible patients.

Verbatim wording from the response
“There is an ongoing task and finish group which is leading on this piece of work and has focused on improving clinicians understanding of what to look for, ask about and consider when assessing patient who may fit in this category. If there is a potential consideration, we add a prompt to our electronic patient record, Dialog+, to ask these questions. Whilst it is not expected that mental health clinicians will make a primary diagnosis of menopause we expect it to be on the list of considerations of patients who meet the criteria. For the clinician there must be consideration of what Mental Health and menopausal symptoms might look like, with an awareness of potential for overshadowing, and the need to establish a proper history from the patient. This is supported by the training offered by the Royal College of Psychiatrists and internal training.”

Source location
Response from Somerset NHS Foundation Trust
Page 2 · response
Published 25 April 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop a toolkit supporting menopause information events and group consultations in local areas.

Verbatim wording from the response
“A toolkit that supports local areas to provide menopause information events and group consultations is under development to improve access and also to provide a forum for learning for other healthcare professionals. NHS England is working on menopause workforce support packages for employees and employers and developing a range of tools to upskill, including two e-learning packages (Menopause Awareness – e-learning for healthcare and Menopause and people professionals eLearning for healthcare), decision support tools and a self-care factsheet to empower women to understand and self-manage their perimenopause and menopause symptoms, and to point them towards further sources of credible information.”

Source location
Response from NHS England
Page 2 · response
Published 25 April 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Promote high-quality and equitable menopause care coverage for all.

Verbatim wording from the response
“Anne’s tragic death has highlighted important gaps in the care of women experiencing perimenopause or menopause and the potential for improvements. NHS England will continue to promote high quality and equitable coverage of menopause care for all.”

Source location
Response from NHS England
Page 4 · response
Published 25 April 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Update menopause and mental health guidance following surveillance of relevant evidence and recommendations.

Verbatim wording from the response
“We note your report also mentions a previous prevention of future death report sent to NICE, NHS England and Somerset NHS Foundation Trust in June 2024 on a similar matter. Within our response, sent in August 2024, we stated that following publication of the menopause update in November 2024, we would assess if any further changes relating to mental health and menopause are needed, in response to the HSIB recommendation and taking into account the issues raised in the initial PFD.”

Source location
Response from NICE
Page 2 · response
Published 25 April 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NHS England and the Royal Colleges are better placed to address the lack of NHS menopause specialists and services.

Verbatim wording from the response
“4. Lack of menopause specialists or menopause services in the NHS”

Source location
Response from NICE
Page 2 · response
Published 25 April 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NHS England and the Royal Colleges are better placed to address the lack of specialist menopausal care and GP upskilling.

Verbatim wording from the response
“5. There has not been a roll-out of specialist menopausal care and upskilling of GPs, as was promised in a previous PFD.”

Source location
Response from NICE
Page 2 · response
Published 25 April 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Employing organisations determine locally mandated menopause training according to their priorities and patient needs.

Verbatim wording from the response
“2. Locally mandated – each employing organisation will determine what should be mandated to all or most of their staff to meet priorities and patient needs. This training varies between organisations, with some similarities.”

Source location
Response from NHS England
Page 3 · response
Published 25 April 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Professions and royal colleges determine profession- or role-specific menopause training standards and curricula.

Verbatim wording from the response
“3. Profession or role specific mandated – this is determined by the respective professions and royal colleges and will form part of standards for professional development and curriculum for future trainees.”

Source location
Response from NHS England
Page 3 · response
Published 25 April 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Setting undergraduate and trainee doctors’ curricula, including compulsory menopause training, is outside NICE’s responsibility.

Verbatim wording from the response
“3. No compulsory training in menopause”

Source location
Response from NICE
Page 2 · response
Published 25 April 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The General Medical Council and Health Education England are responsible for considering menopause training curricula.

Verbatim wording from the response
“Again, we do not consider that this concern is directly for NICE as we are not responsible for setting the curriculum for undergraduate and trainee doctors in the UK, this is the role of the General Medical Council (GMC). We understand that there is currently work being done to integrate menopause care into both GP and specialist training curricula, with menopause as part of the GP Specialty Training Curriculum (although still not a standalone module) and the RCOG launching a Special Interest Training Module (SITM) in Menopause Care in 2024. However, only a very small number of trainees will access this. It is the view of our consultant clinical advisers that menopause care is not consistently or comprehensively taught across all UK medical schools, and there is no national standard requiring in-depth menopause training for all medical students.”

Source location
Response from NICE
Page 2 · response
Published 25 April 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NICE considers its updated menopause and mental health guidelines up to date and continues surveillance of relevant studies.

Verbatim wording from the response
“We note your report also mentions a previous prevention of future death report sent to NICE, NHS England and Somerset NHS Foundation Trust in June 2024 on a similar matter. Within our response, sent in August 2024, we stated that following publication of the menopause update in November 2024, we would assess if any further changes relating to mental health and menopause are needed, in response to the HSIB recommendation and taking into account the issues raised in the initial PFD.”

Source location
Response from NICE
Page 2 · response
Published 25 April 2025
Open published response
26 Jun2024
Somerset
Concerns raised4
1. Lack of understanding and appreciation of the link between menopause and mental health decline
2. Lack of continuity and joined-up care between menopause and mental health treatment
3. Absence of guidance or published policy on joined-up care for women experiencing menopause
1. Absence of guidance or published policy on the link between menopause and mental health decline
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 9
1. Action
  Provide menopause training for GPs, mental health clinicians and other relevant colleagues.
  Stated by Somerset NHS Foundation TrustStated in progress
2. Action
  Make Royal College of Psychiatrists menopause training available to psychiatry colleagues.
  Stated by Somerset NHS Foundation TrustStated completed
3. Action
  Prepare guidance for colleagues on considering menopause and perimenopause during assessment of relevant patients.
  Stated by Somerset NHS Foundation TrustStated in progress
1. Action
  Share menopause and mental-health assessment guidance across inpatient and community services.
  Stated by Somerset NHS Foundation TrustStated planned
2. Action
  Establish whether a menopause assessment prompt can be added to Dialog+.
  Stated by Somerset NHS Foundation TrustStated in progress
3. Action
  Support development of tools and interventions to upskill GPs in menopause care and improve access to treatments.
  Stated by NHS EnglandStated planned
4. Action
  Conduct an exceptional surveillance review of the menopause guideline and available evidence on menopause-related mental-health risks.
  Stated by National Institute for Health and Care ExcellenceStated in progress
5. Action
  Assess whether further menopause and mental-health changes are needed after the updated guideline is published.
  Stated by National Institute for Health and Care ExcellenceStated planned
6. Action
  Operate a multidisciplinary task and finish group to develop information-sharing arrangements on menopause and mental health.
  Stated by Somerset NHS Foundation TrustStated in progress
Respondent positions 2
1. Position
  Women are not universally or uniformly at risk of psychological symptoms during the menopause transition.
  Stated by NHS EnglandDisputes the concern
1. Position
  NICE is best placed to provide further information about national guidance on menopause and mental health decline.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Michelle Patricia Moore · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Michelle Patricia Moore, who had a longstanding history of anxiety and an acute deterioration in her mental health, was found deceased at home on 31 October 2023. The inquest concluded with a short-form conclusion of suicide, with the medical cause of death recorded as compression of the neck and suspension by a ligature. The principal concerns were a lack of continuity and joined-up care between treatment for menopausal symptoms and mental health care, and an apparent absence of guidance, training and policy concerning links between menopause and mental health decline.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of understanding and appreciation of the link between menopause and mental health decline
Wider context from the report
“There appeared to be a lack of continuity and joined-up care between those trying to treat Mrs Moore’s menopausal symptoms and those trying to treat her mental health presentation and this suggested: (a) A lack of understanding and appreciation of the menopause and the effect this hormonal change and/or imbalance may have on women; and (b) A lack of understanding and appreciation of a potential link between menopause and a woman experiencing mental health decline. I referred in questioning to the recognised mental health conditions of Post Natal Depression (PND) and Post Natal Psychosis (PNP) where it appears to be more widely understood and appreciated amongst treating professionals that childbirth and the hormonal imbalance/upheaval can acutely affect a woman’s mental wellbeing and state of mind. However, the same awareness and/or appreciation does not appear to exist when, later in life, a woman may suffer a mental health decline due to acute hormonal changes brought about by the menopause (whether or not this is treated with HRT). There appears to be a complete absence of national and/or local guidance or published policy (none was brought to my attention on questioning of the clinicians) concerning: (a) The potential for a link between menopause and mental health decline. (b) The need for joined-up care between those trying to treat women at this stage of their lives. (c) Training and learning around hormone levels, HRT and antidepressants and the potential for a holistic approach to inform awareness and understanding. ”
Source location
Michelle Patricia Moore · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of continuity and joined-up care between menopause and mental health treatment
Wider context from the report
“There appeared to be a lack of continuity and joined-up care between those trying to treat Mrs Moore’s menopausal symptoms and those trying to treat her mental health presentation and this suggested: (a) A lack of understanding and appreciation of the menopause and the effect this hormonal change and/or imbalance may have on women; and (b) A lack of understanding and appreciation of a potential link between menopause and a woman experiencing mental health decline. I referred in questioning to the recognised mental health conditions of Post Natal Depression (PND) and Post Natal Psychosis (PNP) where it appears to be more widely understood and appreciated amongst treating professionals that childbirth and the hormonal imbalance/upheaval can acutely affect a woman’s mental wellbeing and state of mind. However, the same awareness and/or appreciation does not appear to exist when, later in life, a woman may suffer a mental health decline due to acute hormonal changes brought about by the menopause (whether or not this is treated with HRT). There appears to be a complete absence of national and/or local guidance or published policy (none was brought to my attention on questioning of the clinicians) concerning: (a) The potential for a link between menopause and mental health decline. (b) The need for joined-up care between those trying to treat women at this stage of their lives. (c) Training and learning around hormone levels, HRT and antidepressants and the potential for a holistic approach to inform awareness and understanding. ”
Source location
Michelle Patricia Moore · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Absence of guidance or published policy on joined-up care for women experiencing menopause
Wider context from the report
“There appeared to be a lack of continuity and joined-up care between those trying to treat Mrs Moore’s menopausal symptoms and those trying to treat her mental health presentation and this suggested: (a) A lack of understanding and appreciation of the menopause and the effect this hormonal change and/or imbalance may have on women; and (b) A lack of understanding and appreciation of a potential link between menopause and a woman experiencing mental health decline. I referred in questioning to the recognised mental health conditions of Post Natal Depression (PND) and Post Natal Psychosis (PNP) where it appears to be more widely understood and appreciated amongst treating professionals that childbirth and the hormonal imbalance/upheaval can acutely affect a woman’s mental wellbeing and state of mind. However, the same awareness and/or appreciation does not appear to exist when, later in life, a woman may suffer a mental health decline due to acute hormonal changes brought about by the menopause (whether or not this is treated with HRT). There appears to be a complete absence of national and/or local guidance or published policy (none was brought to my attention on questioning of the clinicians) concerning: (a) The potential for a link between menopause and mental health decline. (b) The need for joined-up care between those trying to treat women at this stage of their lives. (c) Training and learning around hormone levels, HRT and antidepressants and the potential for a holistic approach to inform awareness and understanding. ”
Source location
Michelle Patricia Moore · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Absence of guidance or published policy on the link between menopause and mental health decline
Wider context from the report
“There appeared to be a lack of continuity and joined-up care between those trying to treat Mrs Moore’s menopausal symptoms and those trying to treat her mental health presentation and this suggested: (a) A lack of understanding and appreciation of the menopause and the effect this hormonal change and/or imbalance may have on women; and (b) A lack of understanding and appreciation of a potential link between menopause and a woman experiencing mental health decline. I referred in questioning to the recognised mental health conditions of Post Natal Depression (PND) and Post Natal Psychosis (PNP) where it appears to be more widely understood and appreciated amongst treating professionals that childbirth and the hormonal imbalance/upheaval can acutely affect a woman’s mental wellbeing and state of mind. However, the same awareness and/or appreciation does not appear to exist when, later in life, a woman may suffer a mental health decline due to acute hormonal changes brought about by the menopause (whether or not this is treated with HRT). There appears to be a complete absence of national and/or local guidance or published policy (none was brought to my attention on questioning of the clinicians) concerning: (a) The potential for a link between menopause and mental health decline. (b) The need for joined-up care between those trying to treat women at this stage of their lives. (c) Training and learning around hormone levels, HRT and antidepressants and the potential for a holistic approach to inform awareness and understanding. ”
Source location
Michelle Patricia Moore · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide menopause training for GPs, mental health clinicians and other relevant colleagues.

Verbatim wording from the response
“Somerset NHS Foundation Trust (SFT) is responsible for the provision of care within 16 GP practices across Somerset. Our Director for Primary Care, who is also a GP and menopause specialist, has been leading training on the menopause for both GP’s and clinicians in mental health since the beginning of the year. This has enabled us to deliver bespoke training for colleagues and there is more arranged specifically for the Learning Disability team and Mental Health, as well as physical health colleagues. To support the integration with other GP practices outside of the Trust our Director for Primary Care works closely with our Medical Director of Integrated and Primary Care to determine if we can offer training/sharing of information more”

Source location
Response from Somerset NHS
Page 1 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Make Royal College of Psychiatrists menopause training available to psychiatry colleagues.

Verbatim wording from the response
“Clinicians in psychiatric services can access the online training offered by the Royal College of Psychiatrists and this was referred to at the inquest by our consultant witness who has undertaken the training. This resource is available to all our psychiatry colleagues and will be included in the guide that is being prepared, please see below.”

Source location
Response from Somerset NHS
Page 1 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Prepare guidance for colleagues on considering menopause and perimenopause during assessment of relevant patients.

Verbatim wording from the response
“Within the Mental Health and Learning Disability Service Group a Task and Finish group has been established to look further at this concern. It is a multi-disciplinary group and has been meeting for the last few months to determine how best we can share information with colleagues. The initial plan is to share with colleagues’ guidance on considering menopause/perimenopause when assessing this patient group. Key themes to consider will be:”

Source location
Response from Somerset NHS
Page 2 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Share menopause and mental-health assessment guidance across inpatient and community services.

Verbatim wording from the response
“These points are relevant to both inpatient and community services, and the guidance will be shared within the coming weeks.”

Source location
Response from Somerset NHS
Page 2 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Establish whether a menopause assessment prompt can be added to Dialog+.

Verbatim wording from the response
“1. Considering perimenopause and menopause as part of assessment – remember to ask the question, and we are establishing if there is potential to put a prompt in Dialog+”

Source location
Response from Somerset NHS
Page 2 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Support development of tools and interventions to upskill GPs in menopause care and improve access to treatments.

Verbatim wording from the response
“NHS England is currently supporting the development of a range of tools and interventions that will help to upskill more GPs in providing menopause care, and to improve access to treatments that can be helpful. GPs are well placed to take a holistic approach to mental health assessment, including menopause as one of the potential causes of mental distress or a decline in mental health.”

Source location
Response from NHS England
Page 2 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct an exceptional surveillance review of the menopause guideline and available evidence on menopause-related mental-health risks.

Verbatim wording from the response
“In March 2023, we received a Healthcare Safety Investigation Branch (HSIB) safety recommendation asking NICE to evaluate the available research relating to the risks associated with menopause on mental health and if appropriate, update existing guidance.”

Source location
Response from NICE
Page 1 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Assess whether further menopause and mental-health changes are needed after the updated guideline is published.

Verbatim wording from the response
“Following publication, our surveillance team will assess if any further changes relating to mental health and menopause are needed, in response to the HSIB recommendation and taking into account the issues raised in your report.”

Source location
Response from NICE
Page 1 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Operate a multidisciplinary task and finish group to develop information-sharing arrangements on menopause and mental health.

Verbatim wording from the response
“Within the Mental Health and Learning Disability Service Group a Task and Finish group has been established to look further at this concern. It is a multi-disciplinary group and has been meeting for the last few months to determine how best we can share information with colleagues. The initial plan is to share with colleagues’ guidance on considering menopause/perimenopause when assessing this patient group. Key themes to consider will be:”

Source location
Response from Somerset NHS
Page 2 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Women are not universally or uniformly at risk of psychological symptoms during the menopause transition.

Verbatim wording from the response
“It is acknowledged that mental health problems can decline in women of menopausal age. There are often biological, social and psychological reasons why women may experience mental health problems at this stage in their lives. Changes in hormones during the menopause can cause existing mental health problems to worsen or can cause women to experience symptoms afresh. This means that women often need some help with their mental health as well as their physical health during the menopause. However, women are not universally or uniformly at risk of psychological symptoms over the menopause transition.”

Source location
Response from NHS England
Page 1 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NICE is best placed to provide further information about national guidance on menopause and mental health decline.

Verbatim wording from the response
“Your Report also raised concerns about a lack of national guidance regarding the issues of menopause and mental health decline. I am aware that your Report has also been sent to the National Institute for Health and Care Excellence (NICE) and the Somerset NHS Foundation Trust. I have not yet had sight of their responses, but I would like to refer you to the NICE guidance on menopause diagnosis and management [NICE guideline NG23], which was published on 12 November 2015. This guideline recommends it is explained to women that they may experience a variety of symptoms associated with menopause, including low mood or anxiety, and sets out some of the available treatments, including HRT and cognitive behavioural therapy. NICE will be best placed to provide you with further information around national guidance.”

Source location
Response from NHS England
Page 2 · response
Published 4 July 2024
Open published response
29 Jan2024
Manchester South
Concerns raised2
1. Lack of awareness of menopause as a factor in mental health deterioration
2. Inadequate support for women experiencing menopause-related mental health deterioration
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Provide funding to Mind in Greater Manchester to raise awareness of menopause and its effects on mental health.
  Stated by Department of Health and Social CareStated completed
AI-generated summary

Shahzadi Khan · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Shahzadi Khan was detained under the Mental Health Act after a manic episode with psychotic symptoms and was discharged from an out-of-area private hospital to her family home. Following inadequate discharge planning, communication problems and a failure to arrange the appropriate community care pathway, she deteriorated and took a fatal overdose of prescribed zopiclone at home. The concerns included the effects of out-of-area placements, poor coordination of local care pathways, and insufficient awareness of menopause as a possible factor in mental health deterioration.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of awareness of menopause as a factor in mental health deterioration
Wider context from the report
“2. There was evidence from her family that her deterioration was in part due to her going through the menopause and that had there been better awareness of this as a factor in mental health deterioration for some women and better support in place, interventions could have taken place at an earlier stage and been more effective. ”
Source location
Shahzadi Khan · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inadequate support for women experiencing menopause-related mental health deterioration
Wider context from the report
“2. There was evidence from her family that her deterioration was in part due to her going through the menopause and that had there been better awareness of this as a factor in mental health deterioration for some women and better support in place, interventions could have taken place at an earlier stage and been more effective. ”
Source location
Shahzadi Khan · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide funding to Mind in Greater Manchester to raise awareness of menopause and its effects on mental health.

Verbatim wording from the response
“To raise awareness of menopause for healthcare staff including the effect of menopause on mental health, funding has been given to Mind in Greater Manchester (this is a partnership of five local Minds working together to ensure people experience better mental health and to support people with their mental health to live well and feel valued in their communities and at work). The funding will:”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 12 February 2024
Open published response
22 Feb2021
Hampshire, Portsmouth and Southampton
Concerns raised1
1. Failure to consider hormonal treatment and hormonal triggers when assessing depression in menopausal or perimenopausal women
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Sarah Jane Buckingham · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Sarah Jane Buckingham died by hanging at her home on 12 August 2019 after a period of depression and a recent voluntary admission to a mental health hospital. The principal concern was that hormonal treatment or hormonal changes associated with perimenopause were not considered by the mental health clinicians treating her depressive illness, despite relevant previous episodes following childbirth.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to consider hormonal treatment and hormonal triggers when assessing depression in menopausal or perimenopausal women
Wider context from the report
“Sarah had been started on Hormone Replacement Therapy (HRT) by her GP in November 2017 as she was peri-menopausal. She began to experience and suffer from symptoms of depression once again in March 2019, and was clinically diagnosed with a depressive illness and anxiety. It was only during a voluntary hospital admission between 28th – 30th July 2019 that Sarah had a blood test taken, which included a hormone profile. This was some four months into her illness and was only taken as 'routine'. It transpired from the evidence at Sarah's Inquest that hormone treatment and/or hormonal triggers for depressive illness were not considered by the Mental Health Clinicians treating Sarah. I heard evidence that those treating Sarah relied on, and followed, NICE Guidelines but that NICE Guidance on Depression does not say anything about the routine monitoring of hormones, or that consideration be given to this potential contributory factor when treating menopausal or perimenopausal women. The significant impact of changing hormones was considered very early on in Sarah's treatment for PND, but was not considered at all during her last episode of depression; with no justification or explanation as to why the impact of changing hormones was considered significant after birth, but not significant during menopause. I believe that an early consideration of these issues when treating a menopausal patient, and understanding of the potential interplay between hormonal changes and depression, may assist in formulating an effective treatment plan for patients such as Sarah. ”
Source location
Sarah Jane Buckingham · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised3

Insufficient availability of specialist menopausal practitioners in primary and Trust-wide care

Lack of mandatory menopausal training for relevant clinical practitioners

Failure to recognise the clinical importance of menopausal symptoms and care

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.14

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.7

Concerns raised4

Lack of understanding and appreciation of the link between menopause and mental health decline

Lack of continuity and joined-up care between menopause and mental health treatment

Absence of guidance or published policy on joined-up care for women experiencing menopause

Absence of guidance or published policy on the link between menopause and mental health decline

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Actions described in response 14

Respondent positions 7

Actions described in response 9

Respondent positions 2