Nursing Standard wrote about nurse Jardine Williams, who worked at Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust and was found dead at home in Carlisle on 24 March 2025 several hours after she told a 999 call handler her mental health was worsening and she had a plan to take her own life.

The coroner explored that the call handler had not asked questions about immediacy of suicide and instead followed a standard pathway without escalating urgency. 

‘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,’ Mr Cousins said.

The call, made by Ms Williams at 5.16pm, was tagged as a category 3, with a planned response time of 120 minutes. It was passed on to the Cumbria Health on Call primary and urgent healthcare service, which attempted to contact Ms Williams four times between 6.14 and 6.54pm, without success. An ambulance arrived at her home just before 9pm, when she was found dead. 

The coroner said it was not possible to determine if the ambulance had arrived earlier whether the death could have been avoided. Jardine died after witnessing a particularly traumatic incident at work

Once again this highlights how much more needs to be done to support our professionals and always keep suicide risk at the forefront of our minds