Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0174, written 16 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 | 16 Mar 2026 |
|---|---|
| Reference | 2026-0174 |
| Deceased | Jardine Williams |
| Coroner | Andrew Cousins |
| Coroner area | Cumbria |
| Category | Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
MR ANDREW COUSINS HM ASSISTANT CORONER County of Cumbria Allerdale House New Bridge Road Workington, CA14 3YJ REGULATION 28 REPORT TO PREVENT FUTURE DEATHS JARDINE WILLIAMS THIS REPORT IS BEING SENT TO: Northwest Ambulance Service, Ladybridge Hall HQ, Chorley New Road, Bolton, BL1 5DD 1 CORONER I am Mr Andrew Cousins HM Assistant Coroner for the 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 On 12 and 13 March 2026, I heard the inquest in the death of Miss Jardine Williams, aged 29 years, at the time of her death on 24 March 2025. The investigation concluded at the end of the inquest, where I returned a narrative conclusion, and found the cause of death to be 1(a) Hanging. 4 CIRCUMSTANCES OF THE DEATH I found that Jardine Williams resided at Flat 2 Harraby Green Hall, Harraby Green Road, Carlisle, Cumbria. Miss Williams was employed as a mental health nurse at Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust. Miss Williams had been experiencing a period of mental ill health, which had been exacerbated following the witnessing of an extremely traumatic incident at her place of work. Miss Williams had sought medical treatment for her mental health condition. At 17.16 hours on 24 March 2025, Miss Williams made a 999 call which was answered by the Northwest Ambulance Service. In this call Miss Williams confirmed she had been experiencing worsening mental health problems and had suicidal thoughts, as well as a plan and an intention to carry out that plan. The 999 call was categorised as a category 3 call, with a planned response time of 120 minutes. The 999 call was passed to Cumbria Health on Call (CHOC) and came into the CHOC system at 17.40 hours. CHOC attempted to contact Miss Wiliams on four occasions between 18.14 hours and 18.54 hours without success. At 20.58 hours on 24 March 2025, an ambulance from the Northwest Ambulance Service arrived at Flat 2 Harraby Green Hall, Harraby Green Road, Carlisle, Cumbria and found that Miss Williams deliberate act, her intent cannot be determined on the balance of probabilities. Whilst Miss Williams died as a result of a It is not possible to determine, on the balance of probabilities, if earlier attendance by the Northwest Ambulance Service at Flat 2 Harraby Green Hall, would have altered this outcome. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed a matter 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. As outlined above, I heard evidence that Miss Williams had made a 999 call which had been answered by the Northwest Ambulance Service (‘NWAS’) who, in turn passed the information to CHOC. (1) I found that the flow of information and communication between NWAS and CHOC was unclear and at times appeared to be confused. The information passed to CHOC at the outset, following the 999 call, appeared to be limited and may not have provided the receiving handler with the full picture of the situation. I was concerned that full and accurate information was therefore not passing between NWAS and CHOC. (2) Thereafter between 18.14 and 18.54 hours, 4 attempts were made by CHOC to call Miss Williams, but no successful contact was made. At 19.48 hours NWAS called CHOC for an update regarding Miss Williams. I heard evidence that as per the agreed procedure, a third and final attempt at contact would be made. By this stage however four unsuccessful attempts had already been made to contact Miss Williams, and the third attempt to contact her had been made at 18.25hours. I considered that the flow of information between CHOC and NWAS appeared to have confused on this issue. At 20.43 hours a further call was made to CHOC from NWAS for an update on the case, and again it was confirmed that no successful contact had been made with Miss Williams. Therefore, the call was taken back by NWAS approximately 2 hours 18 minutes after the third unsuccessful attempt was made to contact Miss Williams. Thereafter, an ambulance attended Flat 2 Harraby Green Hall at 20.58 hours. I did not find that there was a causative link between the call not being returned to NWAS after the third unsuccessful attempt to contact Miss Williams, and the eventual outcome. I was concerned that, in terms of the procedure, the call should have been returned by CHOC to NWAS after the third failed attempt to contact Miss Williams at 18.25 hours, but that the call was not returned to NWAS by CHOC until 20.43 hours. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that Northwest Ambulance Service 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 11 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: Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust 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 16 day of March 2026 Mr Andrew Cousins LLM MRes HM Assistant Coroner County of Cumbria
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.
Mr Andrew Cousins His Majesty’s Assistant Coroner Cumbria Coroners Court By Email Only 14 May 2026 LADYBRIDGE HALL 399 Chorley New Road Bolton BL1 5DD nwas.nhs.uk Dear Mr Cousins Regulation 28 Report – Inquest Touching the Death of Jardine Williams March 2026, which was issued to North I write further to your Prevention of Future Deaths Report dated 16 West Ambulance Service (“NWAS”) following the conclusion of the inquest touching the death of Miss Jardine Williams. th I am aware that you will share my response with Miss Williams’ family, and I firstly wish to express my sincere condolences to them. NWAS’ core purpose is to save lives, prevent harm and provide services which optimise the likelihood of positive patient outcomes. Through the Regulation 28 report, you have requested that NWAS considers your matters of concern and have suggested that action is taken to prevent future deaths occurring in the future. Within this letter, I will address those concerns raised as far as I am able. Concern 1: You found that “the flow of information and communication between NWAS and CHOC was unclear and at times appeared to be confused. The information passed to CHOC at the outset, following the 999 call, appeared to be limited and may not have provided the receiving handler with the full picture of the situation”. You were concerned that full and accurate information was therefore not passing between NWAS and CHOC. As acknowledged by the NWAS Service Delivery Manager during the inquest, and reiterated here for the purposes of this response, the initial transfer of Ms Williams’ call by NWAS to Cumbria Health On Call (CHOC) should not have occurred as the NHS pathways triage indicated a risk of suicide, which is an exclusion to CHOC triaging the call. March 2025. The call was passed to CHOC, The call was made by Ms Williams to NWAS at 17:16hrs on 24 albeit in error, at 17:40hrs via the Interoperability Toolkit (ITK), which is a method of electronic referral. The transfer of information via ITK relies on the NWAS clinician selecting what they consider relevant for the receiving provider. As a result, it does not enable full transfer of the assessment or all associated information. th It is acknowledged that additional details were recorded during the call which, if shared, would have provided further clarity and context. However, ITK does not support the transmission of complete clinical notes from the 999 call. Booking and Referral Standard (BaRS) is an alternative software solution which offers this functionality and is used between NWAS and the Greater Manchester Clinical Assessment Service (GMCAS). Headquarters: Ladybridge Hall, 399 Chorley New Road, Bolton BL1 5DD Delivering the right care, at the right time, in the right place; every time. The BaRS connection between NWAS and the GMCAS was implemented as part of a user case and test of change for NHS England, however, BaRS is not yet universally standardised across all providers. ITK remains the current national interoperability standard. BaRS is expected to replace ITK as the national standard; however, this transition is being directed at a national level, and there is no confirmed implementation date at this time. As such, all systems continue to operate under the existing ITK requirements until formal national instruction is issued. Concern 2: You state “thereafter between 18:14 and 18:54 hours, 4 attempts were made by CHOC to call Miss Williams, but no successful contact was made. At 19:48hrs, NWAS called CHOC for an update regarding Miss Williams. I heard evidence that as per the agreed procedure, a third and final attempt at contact would be made. By this stage however four unsuccessful attempts had already been made to contact Miss Williams, and the third attempt to contact her had been made at 18:25hrs”. You considered that the flow of information between CHOC and NWAS appeared to have confused the issue. The call from Ms Williams to NWAS was correctly categorised as a Category 3 at 17:20 and reviewed by a senior clinician at 17:32, within the 15-minute target time for clinical review. Although erroneously transferred, the agreement in place between NWAS and CHOC states that upon receipt of a referral, CHOC are to contact the patient to conduct their own triage. Should the patient not answer the telephone, a further two attempts should be made, following which the call should be passed back to NWAS. In line with our respective responsibilities, NWAS called CHOC for an update at 19:45 and were informed by the CHOC call handler that only two attempts had been made to contact Miss Williams and a third attempt would be made prior to CHOC passing the incident back to NWAS. CHOC confirmed in their evidence, dealt with at inquest under Rule 23 of the Coroners (Inquests) Rules 2013, that between 18:14 and 18:54 hours, they had made four attempts to contact Ms Williams, each without success. The information provided to NWAS on this occasion was therefore incorrect. At 20:43, NWAS chased CHOC again and were informed a third call had been made with no answer and the CHOC clinician requested a Category 3 ambulance. The ambulance arrived on scene at 20:58, and after obtaining access with the assistance of the fire service, Ms Williams was sadly found to be deceased at 21:25. Since this inquest, NWAS’ Mental Health Liaison Lead contacted CHOC to review the incident collectively. This review was undertaken with CHOC’s Medical Director and Digital Operations/Programme Manager. CHOC have acknowledged the evidence already provided by NWAS that the incident should not have been transferred to CHOC due to the identified risk of suicide and that the information provided on this occasion ought to have contained more context. It was also acknowledged by CHOC that, as the incident was categorised as a Category 3 response, it should have been returned by CHOC following the third unsuccessful attempt to make contact, which did not occur. NWAS and CHOC work closely in partnership and place significant emphasis on effective communication between our organisations. Call pathways and incidents are routinely reviewed to maintain a strong governance framework and to support ongoing service improvement. The continued collaborative communication and incident review processes between NWAS and CHOC demonstrates our shared commitment to delivering the highest standards of care and to learning from all available opportunities. I am sorry that you felt it necessary to issue a Prevention of Future Deaths Report to NWAS. If you require any further clarification or information, please do not hesitate to contact the Trust’s Deputy Director of Corporate Affairs, Emma Shiner. Yours sincerely Chief Executive
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