March 26, 2026

Jardine Williams (1): Prevention of future deaths report

Mental Health related deaths

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Date of report: 16/03/2026

Ref: 2026-0173

Deceased name: Jardine Williams

Coroner name: Andrew Cousins

Coroner Area: Cumbria

Category: Mental Health related deaths

This report is being sent to: NHS England

	REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
	THIS REPORT IS BEING SENT TO: NHS England: [REDACTED]
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 into 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 [REDACTED] Whilst Miss Williams died as a result of a deliberate act, her intent cannot be determined on the balance of probabilities. 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 MATTER OF CONCERN is as follows. As outlined above, I heard evidence that Miss Williams had made a 999 call which had been answered the Northwest Ambulance Service who, in taking information from Miss Williams, followed the pathway questions prescribed by NHS England. In the 999 call, Miss Williams had stated that she had a plan to take her own life, and an intent to do so. I was informed that there was no question in the pathway that sought to address the immediacy of that plan that was being stated. I noted that the absence of this information, and an absence of this question from the pathway, may not have assisted the call handler in compiling as clear a picture as possible about the case they were receiving.
6	ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that NHS England 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: [REDACTED] [REDACTED] Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust Northwest Ambulance Service 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