PORTSMOUTH — A coroner has issued a Prevention of Future Deaths report raising concerns about Portsmouth Hospitals University Trust's handling of a bullying investigation that preceded the suicide of A&E manager Sam Carter in September 2022. The coroner ruled that on 16 September 2022, Carter, aged 55, died by suicide after acting on impulse following stress caused by a work investigation and a personal life incident.

The trust began a formal investigation into alleged misconduct by Carter in May 2022 after a junior staff member accused her of rude and aggressive behaviour. The complaint followed an incident in which Carter had asked the junior to tie her hair up and not use the ambulance entrance, and was circulated to about 60 members of staff. The investigation lasted 100 days and was still ongoing at the time of her death.

The coroner's report raised concerns about delays in resolving the investigation and the ease with which the allegations were made public. A report by Verita commissioned by the trust in June 2023 described the handling of the case as poorly specified, unacceptably delayed, and unfair. Verita also reviewed the workplace culture at the trust, but the trust did not permit Carter's family or the BBC to read that section of the document. In messages to colleagues, Carter said she felt unsupported by her line manager and that the investigation felt like a "witch hunt".

Carter's family said in a statement that the trust had failed to provide updates and reassurance during the disciplinary process, which left their mother increasingly anxious and depressed. The family said that following the suicide there was a total lack of communication or letters of condolence, and that it took up to a year to return their mother's personal items.

"Sam had been treated deplorably throughout the disciplinary process as a second-rate citizen and the trust had shown little to no compassion or kindness to any member of our family," the family said. They said the trust fell way below the standard expected and showed not an ounce of common decency to a bereaved family.

Several former staff members spoke as part of an investigation into an alleged culture of workplace bullying and harassment at the trust. Allegations span the past decade and include a flawed and unfair internal investigation that contributed to Carter's suicide.

"We recognise that at times we have not always provided the level of support our staff deserve and are genuinely sorry for the impact this has had on people including Samantha and her family," Portsmouth Hospitals University Trust said in a statement. The trust said it remained committed to learning, improving, and fostering an inclusive and supportive environment.