Tania Jarman: Prevention of future deaths report
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Date of report: 12/03/2026
Ref: 2026-0143
Deceased name: Tania Jarman
Coroner name: Elizabeth Wheeler
Coroner Area: Cheshire
Category: Suicide (from 2015)
This report is being sent to: Department of Health and Social Care
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: Department of Health and Social Care | |
| 1 | CORONER I am Elizabeth WHEELER, Assistant Coroner for the coroner area of Cheshire |
| 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. |
| 3 | INVESTIGATION and INQUEST On 01 March 2024 I commenced an investigation into the death of Tania Louise JARMAN aged 54. The investigation concluded at the end of the inquest on . The conclusion of the inquest was a narrative: Suicide – contributed to by the loss of protective factors |
| 4 | CIRCUMSTANCES OF THE DEATH Tania Jarman died on 27 February 2024. She died aged 54 at Park House, a non-clinical crisis placement. She died as a result of a ligature [REDACTED]. She tied this ligature with the probable intention to end her own life. In the days leading up to her death, her mental health had worsened and she had had a number of crisis contacts with mental health services. The last of these was the day before she died, which had led to her admission at the crisis placement. Her admission to the crisis placement removed her from known protective factors including the presence of her mother and the safe space which was her home. The impact of this removal was not fully appreciated at the time the referral was made and accepted. In the week before she died (late February 2024), the evidence provided to me in court is of multi-day waits for beds and a national shortage of beds (rather than just a local shortage). The Trust recognised that this long-standing shortage of beds had the potential to start hardening clinical attitudes so the threshold for referring for a bed was higher than clinically required. |
| 5 | CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) 1. There is a long standing and well publicised concern that there are fewer mental health beds than patients who are assessed as needing these. I draw your attention to the fact that this situation is ongoing and continues to pose a risk to life. 2. In addition, the fact that this situation is longstanding now raises the risk that clinical decisions as to bed referrals may use an artificially elevated threshold for referral because decision makers are “hardened”. This potentially denies beds to patients who do in fact have a clinical need for them. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have 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 May 07, 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 I have also sent it to: 1. Tania Jarman’s family 2. Mersey Care NHS Foundation Trust 3. We Change Lives who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He 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 | 12/03/2026 Elizabeth WHEELER Assistant Coroner for Cheshire |