UK Inquiry Tracker

James Stewart

PFD Report Response Pending Ref: 2026-0221

Coroner Robert Cohen

Coroner Area Cumbria

Coroner's Concerns (AI summary)

Flow Coordinators arranging patient discharges may lack information about patient vulnerabilities, potentially leading to unsuitable arrangements being made.

View full coroner's concerns

(1) I heard evidence from a Flow Coordinator who was responsible for taking the practical steps to arrange a patient's discharge after the treating clinicians had determined that the patient was medically fit. I understand that the Flow Coordinator is to make the necessary logistical arrangements for discharge, not to decide whether discharge is appropriate. However, the evidence was that the Flow Coordinator would not necessarily be briefed on any particular vulnerabilities that a patient had. For instance, in this instance Mr Stewart had made repeated threats to harm himself, including on the railway, which the Flow Coordinator did not know of. She considered making arrangements for him to travel home by train, which might have been especially risky. Whilst these matters did not eventuate in this inquest, I consider that not giving Flow Coordinators information about patient vulnerability risks them making unsuitable arrangements.

Part of a Series

2 separate reports were issued from this inquest, each sent to different organisations.

2014-0526
Sent to: Bedfordshire Clinical Commissioning Group

All responded

This report (2026-0221) is shown above.

Sent To

North Cumbria Integrated Care NHS Foundation Trust

Response Status

Linked responses 0 of 1

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 3 January 2025 an investigation was commenced into the death of James Patrick. The conclusion of the inquest was: Suicide.

Mr Stewart's death was contributed to by neglect, being the decision to prematurely discharge him and the failure to intervene when concerns were raised as to his safety prior to his discharge. I found that the medical cause of death was: 1a Multiorgan Failure 1b Cardiac Arrest 1c Hanging II

Circumstances of the Death

My conclusions as to the circumstances of Mr Stewart's death were as follows: James Stewart was 52 years old. He had a past medical history of mental illness and drug and alcohol abuse. On 21st December 2024 he came to the notice of Cumbria Police and made threats to harm himself. He was detained under the Mental Health Act. It was identified that Mr Stewart was also in alcohol withdrawal and he was admitted to the Cumberland Infirmary. His initial period of detention under the Mental Health Act expired. Thereafter, Mr Stewart continued to express a settled intention to harm himself. He was detained under section 5 of the Mental Health Act but it was then determined that detention was not required and that he would remain in hospital voluntarily for alcohol detoxification. A decision was made to discharge Mr Stewart on 26th December 2025. This was premature: Mr Stewart was still suffering from the symptoms of alcohol withdrawal, had not been reassessed by the Psychiatric Liaison Team, and required ongoing treatment. Mr Stewart had understood that transport would be provided to return him to his home in Wales, but the hospital did not consider that this was necessary or appropriate. Mr Stewart went to leave the hospital. As he did so he made a gesture indicating an intention to hang himself. Despite a Health Care Assistant raising concerns, the discharge continued. Mr Stewart went to a nearby hotel where he placed a ligature around his neck and rendered himself unconscious. He was found and returned to the hospital, but had sustained catastrophic injuries which were incompatible with life. Mr Stewart's death was confirmed at 2:10 on 27th December 2024.