Charlotte Jones: Prevention of future deaths report
Skip to related content
Date of report: 11/03/2026
Ref: 2026-0149
Deceased name: Charlotte Jones
Coroner name: Kirsty Gomersal
Coroner Area: Cumbria
Category: Alcohol drugs and medication related deaths
This report is being sent to: Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust | Recovery Steps Cumbria
 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| 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 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 information about service users whether or not the service user has been accepted onto a particular treatment pathway. |
| 6 |  ACTION SHOULD BE TAKENIn 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 | 1 day of March 2026 Miss Kirsty J Gomersal LLB HM Senior Coroner County of Cumbria |