Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0149, written 11 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 | 11 Mar 2026 |
|---|---|
| Reference | 2026-0149 |
| Deceased | Charlotte Jones |
| Coroner | Kirsty Gomersal |
| Coroner area | Cumbria |
| Category | Alcohol, drug and medication related deaths |
| Organisation named | Cumbria, Northumberland, Tyne and Wear 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.
MISS K J GOMERSAL HM SENIOR CORONER County of Cumbria Allerdale House New Bridge Road Workington, CA14 3YJ REGULATION 28 REPORT TO PREVENT FUTURE DEATHS CHARLOTTE LOUISE JONES THIS REPORT IS BEING SENT TO: Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust of Jubilee Road, Gosforth, Newcastle-upon-Tyne, NE3 3XT Recovery Steps Cumbria of 6 Finkle Street, Workington, CA14 2AY 1 CORONER I am Miss Kirsty Gomersal HM Senior Coroner for County of Cumbria 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: https://www.legislation.gov.uk/ukpga/2009/25/contents http://www.legislation.gov.uk/uksi/2013/1629/contents 3 INVESTIGATION and INQUEST Miss Charlotte Louse Jones died on 10 February 2025 at her home address, 70 Valley View Road in Whitehaven. Following post-mortem examination, the medical cause of Miss Jones’ death was found to be: 1(a) Acute Alcohol Toxicity with Bromazolam An investigation into Miss Jones’ death was commenced on 11 February 2025. An Inquest into Miss Jones’ death was opened on 11 June 2025 by HM Assistant Coroner Robert Cohen. Miss Jones’ inquest was held before me on 5, 6 and 11 March 2026. I delivered my findings, determination and conclusion on 11 March. The determination was: Miss Charlotte Louise Jones had a medical history which included Emotionally Unstable Personality Disorder, Post-Traumatic Stress Disorder, Anxiety and Depression. Miss Jones was prescribed medication including diazepam, pregabalin and zopiclone. Miss Jones was known to use alcohol and other substances. Miss Jones was engaging with support services for her substance and alcohol use. She was engaging with mental health services and was awaiting a formal assessment. Between 3 January 2025 and 6 February 2025, a number of calls were made to mental health services and emergency services either 1 directly or indirectly about Miss Jones. She was admitted to hospital on several occasions following incidents of self-harm. Miss Jones was found unresponsive at her home address (70 Velley View Road in Whitehaven) on 10 February 2025. Her death was confirmed at 12;55. Miss Jones' death was to fatal levels of both alcohol and illicit bromazolam. Although Miss Jones often indicated that she took substances with intent, she would usually self-rescue and seek assistance. She did not on this occasion. Miss Jones' reasons for taking substances on this occasion cannot be determined. It cannot safely be determined that Miss Jones intended to take her life. The conclusion of the inquest was: Alcohol and drug related death 4 CIRCUMSTANCES OF THE DEATH Miss Jones medical history included Emotionally Unstable Personality Disorder, Post- Traumatic Stress Disorder, Anxiety and Depression. She was known to self-harm and use alcohol and other substances. As such, Miss Jones had a “dual diagnosis” / co-occurring conditions. Miss Jones was found deceased at her home address on 10 February 2025. The cause of her death was due to fatal levels of both alcohol and bromazolam (an illicit drug). Miss Jones was engaging with Recovery Steps (in relation to her use of alcohol). She was also engaging with CNTW for mental health support. Miss Jones had been discharged from mental health services in 2024 and was awaiting assessment for reallocation at the time of her death. An assessment appointment had been scheduled for 28 January but Miss Jones had not attended. That appointment had not been rescheduled. Between 3 January and 6 February (the last day Miss Jones was known to be alive), she had multiple attendances in A&E following overdose and self-harm. Multiple calls were made to mental health services, emergency services and Recovery Steps. It was accepted that Miss Jones’ risk to herself from her self-harm was escalating. Evidence at inquest was that there was limited information sharing between CNTW and Recovery Steps about Miss Jones during the period in scope (1 January to 10 February 2025). There were opportunities for closer and more collaborative working and exchange of information. However, this was not causative or contributive to Miss Jones’ death. Following a representative from CNTW giving evidence on 5 March 2026, CNTW put in place some measures to improve co-working including updating the Triage Clinician Process. These measures were outlined to the Inquest by way of supplemental evidence on 6 March 2026. However, I remain concerned that the two organisations do not yet have a procedure to ensure the appropriate exchange of information about service users whether or not the service user has been accepted onto a particular treatment pathway. 5 CORONER’S CONCERNS 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: Whilst CNTW and Recovery Steps have procedures by which information about service users is shared, those procedures are not yet appropriate to ensure adequate exchange of 2 information about service users whether or not the service user has been accepted onto a particular treatment pathway. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe the Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust and Recovery Steps Cumbria has 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 8 May 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Miss Jones’ mother. Miss Jones’ Aunt (and her advocate from AAFDA). Independent Chair I have also sent a copy to: DAC Beachcroft – legal representative for CNTW I am also under a duty to send the Chief Coroner a copy of your response. 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 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 this 11 day of March 2026 Miss Kirsty J Gomersal LLB HM Senior Coroner County of Cumbria 3
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.
Recovery Steps Cumbria
Stocklund House
Castle Street
Carlisle
CA3 8SY
HM Coroner’s Office
Allerdale House
Workington
Cumbria
CA14 3JY
8th May 2026
Dear Miss Gomersal,
Re: Waythrough’s response in regard to the Regulation 28, following the Inquest into the
late Charlotte Jones
I write in response to your Regulation 28 Report to Prevent Future Deaths dated 11 March 2026
concerning the death of Charlotte Louise Jones on 10 February 2025. I respond on behalf of
Waythrough, which operates Recovery Steps Cumbria (“RSC”).
Waythrough has carefully considered the matters of concern set out in your report. We wish to
express our sincere condolences to Miss Jones’ family and friends for their loss. The death of
any individual known to our services is treated with the utmost seriousness, and we have given
detailed consideration to the concerns you have raised.
It is stated within your findings that whilst RSC and Cumbria Northumberland Tyne and Wear
NHS Foundation Trust ("CNTW") have procedures by which information about service users is
shared, those procedures are not yet appropriate to ensure adequate exchange of information
about service users whether or not the service user has been accepted onto a particular
treatment pathway.
Context of Service
Before addressing the specific concern, it may assist the Court to understand the context of the
service provided by RSC. RSC is a specialist drug and alcohol recovery service for adults over
the age of 18 who have an identified alcohol or drug need and who reside in Cumbria. The
service is 100% funded by the local authority through public health teams. Engagement with the
service is voluntary and those accessing the service have the option to consent or decline
whether information about their care is shared with other agencies. RSC is delivered by
Waythrough and operates a person-centred, recovery-oriented model underpinned by trauma-
informed practice, delivering inclusive support pathways tailored to individuals' specific needs
and varied goals.
Registered address: Inspiration House, Unit 22, Bowburn North Industrial Estate DH6 5PF.
Waythrough Charity (Waythrough) is a company registered in England (Registered Charity
No. 515755 Registered Company No 182 0492, VAT 413 2088 32, Registered Provider 4713)
RSC operates three primary treatment pathways: an opioid pathway, an alcohol pathway, and a
non-opioid and non-dependent alcohol pathway. Charlotte was supported on the non-opioid
and non-dependent alcohol pathway. Under this pathway, the prescribed intervention follows a
structured programme of approximately 12 sessions, progressing through engagement and
building motivation for change, to addressing triggers, high-risk situations and coping skills, and
then to lapse/relapse prevention and forward planning. Harm reduction information and
psychosocial interventions, delivered with a trauma-informed approach, are provided
throughout the treatment journey.
In addition to primary appointments, individuals have access to drop-in sessions and group
work. Charlotte engaged meaningfully with these services and participated actively in group
sessions, demonstrating openness and honesty in those settings. In working with Charlotte,
RSC also focused on meaningful activities and wider social circumstances as part of her
recovery planning. Where RSC identifies that another agency is involved with an individual, it
considers whether joint working is required, and there is good evidence of collaborative working
with Probation in Charlotte's case.
RSC and CNTW have a Co-occurring Mental Health and Substance Use Joint Working Protocol
that is operational. The purpose of this is to ensure that recovery centred asset-based care is in
place for individuals with a co-occurring need, and to ensure that true cohesion and dovetailing
of the co-occurring agenda is adopted and applied consistently and effectively in practice to all
in North Cumbria.
The Support Provided to Charlotte
To provide context for the Coroner's concern, it is relevant to set out the nature and extent of
RSC's involvement with and support of Charlotte.
Charlotte had been known to addiction services in Cumbria for several years. Her last episode
of support commenced in August 2023, when she was referred to the service by Probation for
support in relation to her alcohol use. Charlotte presented with co-occurring needs, including
emotional difficulties and previous trauma, alongside periods of increased alcohol use. RSC
utilised validated screening instruments including the GAD-7 (generalised anxiety disorder self-
assessment tool) and physical health screening tools to identify and monitor any mental health
needs, making onward referrals where appropriate.
RSC continued to work with Charlotte on an ongoing basis, including during periods of relative
stability when she was not turning to alcohol. Although consideration was given to discharge at
points where Charlotte had completed the interventions RSC could offer, the service continued
to work with her given her fluctuating circumstances.
In the period leading up to Charlotte's death, RSC maintained regular contact with her,
conducted internal case discussions, liaised with relevant agencies including the police,
probation, housing, and hospital services, and escalated concerns where appropriate.
During Charlotte’s engagement with RSC, the service referred her to the CNTW Community
Treatment Team on a number of occasions and also kept in touch with CNTW to ascertain
where Charlotte was on the waiting list.
Registered address: Inspiration House, Unit 22, Bowburn North Industrial Estate DH6 5PF.
Waythrough Charity (Waythrough) is a company registered in England (Registered Charity
No. 515755 Registered Company No 182 0492, VAT 413 2088 32, Registered Provider 4713)
Multi-Agency Collaborative Working
RSC participated actively in multi-agency collaborative working in respect of Charlotte. For a
period of approximately 12 weeks prior to Charlotte's death, multi-agency collaborative work
was undertaken through the Local Focus Hub, a forum operated through Cumbria Police for
anti-social behaviour concerns. This forum has sign-up from local agencies and provides a
platform for agencies to coordinate their responses to individuals of concern. RSC attended
those meetings and actively contributed to the planning and oversight of Charlotte's case within
that forum.
It is important to note that the Local Focus Hub is not a statutory meeting, and attendance is
voluntary, RSC's participation in that forum demonstrates good practice and reflects the
willingness of local services to adapt their remit and collaborate to use their collective skillsets
in the best interests of the individual.
The Existing Joint Working Protocol with CNTW
Since October 2023, there has been a Co-Occurring Mental Health and Substance Use Joint
Working Protocol in place between RSC and CNTW. The purpose of this protocol is to ensure
that recovery-centred, asset-based care is in place for individuals with a co-occurring need,
and to ensure that true cohesion and dovetailing of the co-occurring agenda is adopted and
applied consistently and effectively in practice to all in North Cumbria.
The key principles of the protocol include that service users should not be prevented from
accessing a particular service due to substance use or severe mental health; that co-occurring
conditions should be seen as the norm not the exception; and that a collaborative approach is
required to meet such needs. The protocol also provides that where a service user is receiving
care from both services, they will have a joint care plan and risk assessment, and that
discharge from either service should be a discussed and planned process agreed through the
wider MDT.
Under the protocol, monthly interface meetings are held between RSC and CNTW, with
allocated time slots that can be booked by staff from either organisation. These sessions allow
clinicians from both services to bring complex, co-occurring cases for discussion, and patients
do not have to be accepted into a CNTW service to be discussed at these meetings.
Where an agreement cannot be reached between both services on a complex matter, each
service has an escalation process.
Response to the Coroner's Concern
RSC alongside our colleagues from CNTW recognise and accept that there is an opportunity to
collectively strengthen our partnership working. Following the matters of concern raised,
immediate action was taken as follows:
1. A partnership meeting was held between RSC and CNTW to discuss the matters of
concern, identify immediate actions, and create a longer-term plan for enhanced care
Registered address: Inspiration House, Unit 22, Bowburn North Industrial Estate DH6 5PF.
Waythrough Charity (Waythrough) is a company registered in England (Registered Charity
No. 515755 Registered Company No 182 0492, VAT 413 2088 32, Registered Provider 4713)
delivery for individuals with co-occurring needs. An initial meeting took place on 15 April
2026, where actions were agreed to include a comparison between the current protocol
and CNTW's organisational stance on co-occurring substances.
2. Creation and implementation of a working group to jointly review the co-occurring joint
protocol has been initiated, which includes staff members from both organisations.
In addition, RSC has undertaken the following actions:
• A review of how mental health information is flagged and captured within RSC's clinical
management system SystmOne has been undertaken, to ensure that mental health
concerns and onward referrals are more prominently recorded and visible to all
practitioners working with an individual.
• The addition of a mental health crisis referral as an incident category within The Hub,
Waythrough's management of incidents system, to ensure that escalations relating to
mental health crises are formally captured and tracked.
• A longer-term plan to re-launch a refreshed and updated co-occurring pathway across
North Cumbria, initially with a view of rolling this out across the wider CNTW catchment.
The protocol will include clear escalation routes, improved communication pathways
between RSC and CNTW, and a formalised process for following up on onward referrals
where a response has not been received within an agreed timeframe. CNTW and RSC are
in the process of cooperatively reviewing the protocol in line with the following aims:
o The potential to apply the protocol across relevant departments, supporting a
consistent approach and clear cross-team accountability;
o To confirm nominated leads within RSC and CNTW to review the operational elements
of the protocol and ensure it is working effectively in practice;
o To review all single points of contact (SPOC) and referral information and ensure the
relevant parties are updated;
o To invest in education and awareness-raising for frontline practitioners so the protocol
is understood and implemented consistently;
o To improve the capture and documentation of information-sharing between RSC and
CNTW, including acknowledgement of information received and clear, timely
responses, to support proper record keeping;
o To strengthen joint care planning and risk assessment, using interface meetings to
address escalating and unmitigated risks, and to ensure the protocol can
accommodate an increased frequency of interface meetings, with a view to holding
these on a weekly basis where clinically indicated.
Registered address: Inspiration House, Unit 22, Bowburn North Industrial Estate DH6 5PF.
Waythrough Charity (Waythrough) is a company registered in England (Registered Charity
No. 515755 Registered Company No 182 0492, VAT 413 2088 32, Registered Provider 4713)
RSC is committed to the review of the joint working protocol with CNTW. RSC considers that the
current period presents a timely opportunity to review how practitioners from both
organisations work together, not solely as a result of Charlotte's case but more broadly in terms
of how collaborative working can be strengthened for all individuals with co-occurring needs.
Conclusion
I hope that the above offers reassurance in respect of how Waythrough has responded to the
issues you have raised. The care provided to Charlotte by RSC was delivered with compassion
and dedication by practitioners who knew her well and worked tirelessly to support her during
an exceptionally difficult period. RSC maintained contact with Charlotte, actively participated
in multi-agency forums to coordinate her care, and escalated concerns to statutory services
where appropriate.
Reducing drug and alcohol related deaths within the county is a priority for Waythrough, and we
are committed to working collaboratively with all partner agencies to learn from and reduce the
number of deaths in the area.
On behalf of all staff at RSC, I would like to pass our sincere condolences to Charlotte's family
and friends.
Yours sincerely
Area Manager
Registered address: Inspiration House, Unit 22, Bowburn North Industrial Estate DH6 5PF.
Waythrough Charity (Waythrough) is a company registered in England (Registered Charity
No. 515755 Registered Company No 182 0492, VAT 413 2088 32, Registered Provider 4713)
See every Prevention of Future Deaths report matching Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.