Natalie Ainsworth
17 Mar 2026 · Coroner Janine Richards · County Durham and Darlington
The coroner's concerns
1. risk assessment fails to consider vulnerability and mental health history
“[the deceased] was a vulnerable missing person considered to be at medium risk. A call was made to Police on the 13th February 2025 at 15:01 hours expressing concern for [the deceased]'s welfare and informing Police of a new address where she may be and informing Police that she had earlier threatened to take her own life. Although the control room recorded that information was passed on to the relevant officer, neither the Inspector who undertook an updated a risk assessment some two hours later, nor the Officer making enquiries, was aware that [the deceased] had threatened to take her own life. This important information was therefore not part of the risk assessment and not factored into subsequent Police actions, including in terms of whether to force entry to the property which was visited by the Police. Further the risk assessment carried out at 1704 hours was not a robust assessment of the risks which were known, or ought to have been known, by Police at that time. In particular the risk assessment fails to consider [the deceased]'s vulnerability as a person with a history of mental health issues, self harm and substance abuse, records incorrectly that there is no indication that the person is likely to take their own life, records incorrectly that the person has no mental health issues, and records incorrectly that the person has not been involved in a violent incident prior to them disappearing. An accurate and robust assessment of risk is essential to ensure that the nature and extent of any Police response is proportionate, and resources deployed appropriately, particularly when welfare/safety concerns are raised, as they were in [the deceased]'s case.”