Jardine Williams
PFD Report
No Identified Response
Ref: 2026-0173
Coroner's Concerns (AI summary)
The 999 call pathway for mental health crises lacks a specific question to assess the immediacy of a stated suicide plan, potentially hindering call handlers from understanding urgent risk.
View full coroner's concerns
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.
Part of a Series
2 separate reports were issued from this inquest, each sent to different organisations.
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2026-0173-wp121101
Sent to: Northwest Ambulance ServiceNo responses yet
This report (2026-0173) is shown above.
Sent To
- NHS England
Response Status
Linked responses
0 of 1
56-Day Deadline
11 May 2026
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 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.
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.
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.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.