Charlotte Jones
11 Mar 2026 · Coroner Kirsty Gomersal · Cumbria
The coroner's concerns
1. inadequate information exchange
“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”
2. lack of follow-up after discharge
“Miss [name redacted] had been discharged from mental health services in 2024 and was awaiting assessment for reallocation at the time of her death”