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

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 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.