James Stewart

Thursday, 04 June 2026 

PRIVATE AND CONFIDENTIAL  
Robert Cohen HM Assistant Coroner for Cumbria 
HM Coroner's Courts 
Allerdale House 
Workington 
Cumbria  
CA14 3YJ 

Dear Mr Cohen 

Re: North Cumbria Integrated Care’s Regulation 28 Response and Action Plan 
Concerning the Inquest into the death of James Patrick Stewart 

I write following the inquest held on 13 and 14 April 2026 into the death of Mr James Stewart. 

You concluded that Mr Stewart died on 27 December 2024 at the Cumberland Infirmary, Carlisle, 
Cumbria.  The medical cause of death was recorded as: 

1a Multiorgan Failure 
1b Cardiac Arrest 
1c Hanging 

You further concluded that Mr Stewart died due to suicide, contributed to by neglect, specifically the 
premature  decision  to  discharge  him  and  the  failure  to  intervene  when  concerns  were  raised 
regarding his safety prior to discharge. 

During the inquest, you identified matters of concern which give rise to a risk of future deaths unless 
action is taken. In accordance with your statutory duty, you issued a Regulation 28 Report to the 
Trust. 

On behalf of the Trust, I would like to reiterate our sincere condolences to Mr Stewart’s family. We 
recognise the profound impact of his death. 

For completeness, I would note that the Trust’s learning response completed in January 2025 was 
based on the contemporaneous evidence available at the time, including accounts from staff directly 
involved in Mr Stewart’s care.  These accounts did not indicate that an explicit expression of intent 
to end his life by hanging had been escalated immediately prior to discharge.  Notwithstanding this, 
I  acknowledge  your  careful  consideration  of  the  evidence  and  accept  the  seriousness  of  your 
findings. The Trust has undertaken extensive reflection on the circumstances of Mr Stewart’s care, 
and is fully committed to ensuring that the learning identified is embedded into clinical practice and 
operational delivery. 

Pillars Building, Cumberland Infirmary, Infirmary Street, Carlisle, Cumbria, CA2 7HY 

Safe, high quality care every time 

 
 
 
 
 
 
 
 
 
 
 
 Matters of Concern and Trust Response - Information available to Flow Coordinators 

You raised concern regarding the adequacy of information provided to Flow Coordinators in relation 
to patient vulnerability, and the associated risk of inappropriate discharge arrangements. 

I  recognise  that  Flow  Coordinators  fulfil  a  non-clinical  coordination  role  once  a  patient  has  been 
deemed medically fit by registered clinical professionals for discharge. However, I accept that this 
function  requires  sufficient  awareness  of  relevant  risks,  particularly  where  patients  present  with 
vulnerability, mental health needs, or safeguarding concerns. 

Actions Taken and Planned 

1. Flow Coordinator Role and Discharge Processes 

I  have  commissioned  a  review  of  the  Band  4  Flow  Coordinator  role  and  associated  discharge 
processes. This includes: 

•  Clarification of role scope, responsibilities, and accountability 
•  Strengthening the flow of relevant clinical and risk information during discharge coordination 
•  Clear escalation expectations where vulnerabilities or risks are identified 
•  Reinforcement  that  discharge  decisions  remain  clinically  led  and  have  a  multidisciplinary 

approach 

2. Transport and Discharge Arrangements 

I have commissioned a review of discharge transport and planning processes, with particular focus 
on vulnerable patients. This includes: 

•  Clarification of roles and responsibilities for transport decisions 
•  Strengthened escalation pathways where transport arrangements present risk 
•  Enhanced documentation of agreed arrangements and contingency planning 

This  work  is  intended  to  ensure  that  discharge  coordination  is  supported  by  appropriate  risk 
awareness and system oversight.   

While I  recognise  that  the  following  was not  identified  by  you  as  a  matter  of  concern  within  your 
Regulation 28 report, I note your findings that Mr Stewart’s discharge was premature, as he was still 
suffering from the symptoms of alcohol withdrawal.  We have therefore identified the following actions 
to address this and to reduce the risk of recurrence:  

3. Alcohol Withdrawal and Detoxification Guidance 

A full review of Trust guidance relating to alcohol withdrawal and detoxification has been initiated. 
This includes: 

•  Clear expectations for discharge decision making during detoxification 
•  Defined escalation requirements where Clinical Institute Withdrawal Assessment for Alcohol 

(CIWA-Ar) scores remain elevated or fluctuate 

•  Guidance on involvement of specialist mental health or liaison services 

 
 
 4. Assurance of CIWA-Ar Scoring and Clinical Response 

We are strengthening audit and assurance processes relating to CIWA-Ar scoring, including: 

•  Accuracy and consistency of scoring and documentation 
•  Timeliness of reassessment 
•  Clinical response and escalation to elevated scores 
•  Oversight of discharge decisions where withdrawal symptoms persist 

Learning from this work is being embedded through governance and clinical education structures. 

Learning from this case will continue to be shared across the organisation through governance and 
leadership forums. Key areas of focus include: 

•  Early recognition and escalation of patient safety concerns 
•  Strengthening multidisciplinary challenge and professional curiosity 
•  Communication and coordination at the point of discharge 
•  Management of co-existing physical health, alcohol dependence, and mental health risks 
•  Standards of documentation and escalation recording 

I want to assure you that the Trust has given careful and thorough consideration to the concerns 
raised within your Regulation 28 Report. We are taking forward a programme of work designed to 
deliver sustainable improvement and reduce the risk of future harm. 

I will continue to oversee this work through our governance framework and ensure that patient safety 
remains central to our organisational priorities. 

I hope this response provides assurance that the matters identified have been taken seriously and 
that meaningful action is being undertaken. 

Yours sincerely, 

Deputy Chief Executive, Executive Medical Director and Responsible Officer 
North Cumbria Integrated Care NHS Foundation Trust

 
 
 
 
  
 Ref   Action  
1 

Implement  process  for 
risk 
sharing  clinical 
information 
during 
discharge 
coordination and 
led 
ensure  MDT- 
discharge 
all 
for 
patients.  This  includes 
mental health services.  
incident 
Strengthen 
reporting 
and 
management  process 
in  relation  to  mental 
health patients to allow 
of 
triangulation 
and 
information 
escalation of risk  
Trust  wide 
learning  

shared 

Lead  
Collaborative  Lead 
Nurse  Emergency 
Care 

Timescale  
31/08/2026  

Assurance / Monitoring  
Emergency 
Care 
Collaborative  Workforce 
Group 

to 

Evidence of Completion  
Update  discharge  documentation 
include: 
-  Mental  health  section.  Has 

involvement 

the 
patient  had  any 
in 
mental  health  services  during  their 
admission or inpatient stay.  
If  patient  has  been  involved  in 
mental health services – consider a 
referral to PLT prior to discharge.  

- 

Patient 
System Manager  

Safety 

31/10/2026 

Incident  reporting  and  management 
floor walk and engagement training. 

Delivering  Quality 
Safety Group 

and 

Training record.  

Corporate 
Manager  

Risk 

31/05/2026 

Patient Safety Group 

2 

3 

Pillars Building, Cumberland Infirmary, Infirmary Street, Carlisle, Cumbria, CA2 7HY 

Safe, high quality care every time