March 26, 2026

Jardine Williams (2): 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: Northwest Ambulance Service

	REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
	THIS REPORT IS BEING SENT TO: Northwest Ambulance Service, Ladybridge Hall HQ, Chorley New Road, Bolton, BL1 5DD
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 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 MATTERS OF CONCERN are as follows. As outlined above, I heard evidence that Miss Williams had made a 999 call which had been answered by the Northwest Ambulance Service (‘NWAS’) who, in turn passed the information to CHOC. (1) I found that the ﬂow of information and communication between NWAS and CHOC was unclear and at times appeared to be confused. The information passed to CHOC at the outset, following the 999 call, appeared to be limited and may not have provided the receiving handler with the full picture of the situation. I was concerned that full and accurate information was therefore not passing between NWAS and CHOC. (2) Thereafter between 18.14 and 18.54 hours, 4 attempts were made by CHOC to call Miss Williams, but no successful contact was made. At 19.48 hours NWAS called CHOC for an update regarding Miss Williams. I heard evidence that as per the agreed procedure, a third and ﬁnal attempt at contact would be made. By this stage however four unsuccessful attempts had already been made to contact Miss Williams, and the third attempt to contact her had been made at 18.25hours. I considered that the ﬂow of information between CHOC and NWAS appeared to have confused on this issue. At 20.43 hours a further call was made to CHOC from NWAS for an update on the case, and again it was conﬁrmed that no successful contact had been made with Miss Williams. Therefore, the call was taken back by NWAS approximately 2 hours 18 minutes after the third unsuccessful attempt was made to contact Miss Williams. Thereafter, an ambulance attended Flat 2 Harraby Green Hall at 20.58 hours. I did not ﬁnd that there was a causative link between the call not being returned to NWAS after the third unsuccessful attempt to contact Miss Williams, and the eventual outcome. I was concerned that, in terms of the procedure, the call should have been returned by CHOC to NWAS after the third failed attempt to contact Miss Williams at 18.25 hours, but that the call was not returned to NWAS by CHOC until 20.43 hours.
6	ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that Northwest Ambulance Service 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

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