Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0270, written 2 Jun 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Jun 2025 |
|---|---|
| Reference | 2025-0270 |
| Deceased | Charlotte Werner |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths |
| Organisation named | University College London Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Charlotte Louise WERNER (died 27.11.24)
THIS REPORT IS BEING SENT TO:
1. Medical Director
University College London Hospitals NHS Trust (UCLH)
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Poplar Coroner’s Court
Bow Coroner’s Court
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 29 November 2024, one of my assistant coroners, Richard Brittain,
commenced an investigation into the death of Charlotte Louise Werner,
aged 13 years. The investigation concluded at the end of the inquest on
28 May 2025. I made a determination at inquest of death by suicide.
4
CIRCUMSTANCES OF THE DEATH
Charlotte hanged herself at home.
5
CORONER’S CONCERNS
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.
1
The MATTERS OF CONCERN are as follows.
Charlotte’s mother formed the view that Charlotte was suffering from an
eating disorder and was under the impression that the referral to a UCLH
dietitian was made, at least in part, in order to explore this.
In fact, Charlotte was never diagnosed with an eating disorder, did not
meet the criteria for a referral on this basis and was referred solely for
consideration of whether her nutritional status was having an impact on
her height.
I found no evidence of any link between Charlotte’s eating and her death.
However, that might be different for another child.
It seems from the evidence I heard that an explanation, perhaps on the
website or in correspondence, that the UCLH dietetic service is not a
mental health service and does not treating eating disorders, could be
helpful.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 28 July 2025. I, the coroner, may extend the
period.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for action. Otherwise, you must explain
why no action is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
• The mother of Charlotte Werner
• HHJ Alexia Durran, the Chief Coroner of England & Wales
I am also under a duty to send a copy of your response to the Chief
Coroner and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I
believe may find it useful or of interest.
2
The Chief Coroner may publish either or both in a complete or redacted
or summary form. She may send a copy of this report to any person who
she believes may find it useful or of interest. You may make
representations to me, the coroner, at the time of your response, about
the release or the publication of your response.
9
DATE SIGNED BY SENIOR CORONER
02.06.25 ME Hassell
3
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