Charlotte Werner
PFD Report
No Identified Response
Ref: 2025-0270
Coroner's Concerns (AI summary)
A lack of clear communication led to a misunderstanding that a dietetic service treated eating disorders, highlighting a need for clarification that it is not a mental health service.
View full coroner's concerns
Charlotte’s mother formed the view that Charlotte was suffering from an eating disorder and was under the impression that the referral to a UCLH dietitian was made, at least in part, in order to explore this.
In fact, Charlotte was never diagnosed with an eating disorder, did not meet the criteria for a referral on this basis and was referred solely for consideration of whether her nutritional status was having an impact on her height.
I found no evidence of any link between Charlotte’s eating and her death. However, that might be different for another child.
It seems from the evidence I heard that an explanation, perhaps on the website or in correspondence, that the UCLH dietetic service is not a mental health service and does not treating eating disorders, could be helpful.
In fact, Charlotte was never diagnosed with an eating disorder, did not meet the criteria for a referral on this basis and was referred solely for consideration of whether her nutritional status was having an impact on her height.
I found no evidence of any link between Charlotte’s eating and her death. However, that might be different for another child.
It seems from the evidence I heard that an explanation, perhaps on the website or in correspondence, that the UCLH dietetic service is not a mental health service and does not treating eating disorders, could be helpful.
Sent To
- University College London Hospitals NHS Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
28 Jul 2025
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 29 November 2024, one of my assistant coroners, Richard Brittain, commenced an investigation into the death of Charlotte Louise Werner, aged 13 years. The investigation concluded at the end of the inquest on 28 May 2025. I made a determination at inquest of death by suicide.
Circumstances of the Death
Charlotte hanged herself at home.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.