Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0143, written 12 Mar 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Mar 2026 |
|---|---|
| Reference | 2026-0143 |
| Deceased | Tania Jarman |
| Coroner | Elizabeth Wheeler |
| Coroner area | Cheshire |
| Category | Suicide (from 2015) |
| Organisation named | Mersey Care NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Department of Health and Social Care 1 CORONER I am Elizabeth WHEELER, Assistant Coroner for the coroner area of Cheshire 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 01 March 2024 I commenced an investigation into the death of Tania Louise JARMAN aged 54. The investigation concluded at the end of the inquest on . The conclusion of the inquest was a narrative: Suicide – contributed to by the loss of protective factors 4 CIRCUMSTANCES OF THE DEATH Tania Jarman died on 27 February 2024. She died aged 54 at Park House, a non-clinical crisis placement. She died as a result of a ligature She tied this ligature with the probable intention to end her own life. In the days leading up to her death, her mental health had worsened and she had had a number of crisis contacts with mental health services. The last of these was the day before she died, which had led to her admission at the crisis placement. Her admission to the crisis placement removed her from known protective factors including the presence of her mother and the safe space which was her home. The impact of this removal was not fully appreciated at the time the referral was made and accepted. In the week before she died (late February 2024), the evidence provided to me in court is of multi-day waits for beds and a national shortage of beds (rather than just a local shortage). The Trust recognised that this long-standing shortage of beds had the potential to start hardening clinical attitudes so the threshold for referring for a bed was higher than clinically required. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. Regulation 28 – After Inquest Document Template Updated 30/07/2021 The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) 1. There is a long standing and well publicised concern that there are fewer mental health beds than patients who are assessed as needing these. I draw your attention to the fact that this situation is ongoing and continues to pose a risk to life. 2. In addition, the fact that this situation is longstanding now raises the risk that clinical decisions as to bed referrals may use an artificially elevated threshold for referral because decision makers are “hardened”. This potentially denies beds to patients who do in fact have a clinical need for them. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 May 07, 2026. 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to: 1. Tania Jarman’s family 2. Mersey Care NHS Foundation Trust 3. We Change Lives who may find it useful or of interest. 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 person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he 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 by the Chief Coroner. 9 Dated: 12/03/2026 Regulation 28 – After Inquest Document Template Updated 30/07/2021 Elizabeth WHEELER Assistant Coroner for Cheshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Parliamentary Under-Secretary of State for
Women’s Health and Mental Health
39 Victoria Street
London
SW1H 0EU
01 May 2026
Ms Elizabeth Wheeler
HM Coroner
Chesire Jurisdiction
Dear Ms Wheeler,
Thank you for the Regulation 28 report of 12 March 2026 sent to the Department of Health
and Social Care about the death of Tania Louise Jarman. I am replying as Parliamentary
Under-Secretary of State for Women’s Health and Mental Health.
Firstly, I would like to say how saddened I was to read of the circumstances of Ms Jarman’s
death, and I offer my sincere condolences to their family and loved ones. The circumstances
your report describes are concerning and I am grateful to you for bringing these matters to
my attention.
The report raises concerns that there is a long standing and well publicised concern that
there are fewer mental health beds than patients who are assessed as needing these. This
situation is ongoing and continues to pose a risk to life. In addition, the fact that this
situation is long standing now raises the risk that clinical decisions as to bed referrals may
use an artificially elevated threshold for referral because decisionmakers are “hardened”.
This potentially denies beds to patients who do in fact have a clinical need for them.
In preparing this response, my officials have made enquiries with NHS England and the
Care Quality Commission to ensure we adequately address your concerns.
System flow
Following this, I understand that NHS Cheshire and Merseyside have been working with
system partners for over two years to improve mental health system flow, supporting
timely access to services appropriate to meet the needs of the individual patient. NHS
England have also, through the Enforcement Undertakings, set out that there needs to be
demonstrable improvement in mental health long waits in Emergency Departments (EDs)
across Cheshire and Merseyside.
NHS Cheshire and Merseyside have an agreed Mental Health Improvement Plan for
Urgent and Emergency Care (UEC). The Mental Health (UEC) Improvement Plan was
agreed by the Cheshire and Merseyside Urgent and Emergency Care Board on 15th
October 2025, with actions to implement the plan taking place simultaneously with
providers in the Cheshire and Merseyside system.
The development of the Mental Health (UEC) Improvement Plan has been undertaken
through the Cheshire and Merseyside Mental Health Programme, specifically through the
Crisis Care workstream. The Plan was endorsed by NHS Cheshire and Merseyside’s
Quality and Performance Committee on 12th March 2026 and will be refreshed for
2026/27. The Plan includes actions to improve access to crisis services and, where
appropriate, mental health beds.
NHS Cheshire and Merseyside’s commissioning intentions, agreed with mental health
providers, state that in 2026/27 we will “build on the existing mental health Urgent and
Emergency Care (UEC) plan to scope single offer for Cheshire and Merseyside” and
ensure full implementation in 2028/29. This will include the continued development of the
Mental Health Crisis Assessment Service (MHCAS) offer, aligning with the MTPF that
states ICBs and mental health providers should develop a plan for delivering their local
approach to establishing mental health emergency departments (also known as MHCAS).
They are also exploring how the development of 24/7 Neighbourhood Mental Health
Centres, also required in national planning guidance, can be incorporated into this offer.
Plans are in place, based upon the capital allocations over the next four financial years
(until 2029/30), to establish MHCAS across the whole of Cheshire and Merseyside. There
are also plans to ensure that there is at least one 24/7 Neighbourhood Mental Health
Centre per borough by 2029/30.
Model of Care
ICBs are currently delivering their 3-year plan to realise the aims of the Mental Health
Inpatient Commissioning Framework (NHS England 2024); with the Medium-Term
Planning Framework (MTPF) reiterating the expectation that ICBs only commission
models of hospital care in line with this framework from 2027/28 onwards. The framework
makes it clear hospital care should be as close to home as possible, and inclusive - and
not determined by exclusion criteria.
Culture of Care Standards
NHS England also published co-produced Culture of Care Standards for Mental Health
Inpatient Services in 2024 and delivered a multi-year support programme to embed them,
ending in March 2026. Having people’s unique needs understood and met is a core
standard. All NHS and major independent providers participated in the support
programme, which includes Ward Leader Development Training, executive mentoring and
support, and support in embedding quality improvement methodologies.
CQC response
CQC have shared the following response to this report. As reported in the Care Quality
Commission’s (CQC) 2024/25 State of Care report1, a high demand for services and long
waits for mental health care are well-known. These are longstanding challenges that have
been exacerbated in recent years by the impact of the COVID-19 pandemic, austerity, the
1 Care Quality Commission’s (CQC) 2024/25 State of Care report
cost-of-living crisis and challenges with housing. Over the last 5 years, CQC have
consistently reported their concerns that when people cannot get the care they need when
they need it, their mental health can deteriorate, and they may then end up requiring
urgent and emergency care.
The 2024/25 report states that although more care is being provided in the community,
access to hospital care is becoming more challenging because of higher thresholds,
delayed discharges and fewer beds. For bed in inpatient services, on average in 2024/25,
the bed occupancy rate (for all mental health overnight beds) was 90%, remaining above
the recommended 85% threshold. For services such as acute admission wards, usual
occupancy rates are higher than the average.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Yours sincerely,
PARLIAMENTARY UNDER-SECRETARY OF STATE FOR
WOMEN’S HEALTH AND MENTAL HEALTH
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