A CORONER has concluded a Worcestershire woman killed herself after "gross failings" by the NHS trust that was caring for her.

A coroner, overseeing the inquest of Charlotte Comer, said "gross failings" by Herefordshire and Worcestershire Health and Care NHS Trust contributed to the death of the 30-year-old, from Earls Croome, near Malvern.

Worcester News: INQUEST: Charlotte ComerINQUEST: Charlotte Comer (Image: Justgiving/Belinda Tonkins)

Worcestershire's senior coroner, David Reid recorded a verdict that Miss Comer died of an overdose with her family by her bedside at Worcestershire Royal Hospital on July 20, 2021 after taking the overdose the day before.

Mr Reid said he found Miss Comer died as the result of failures by the NHS trust and ordered a rare prevention of future deaths report be completed - such was the concerns he had with the trust's "gross failures."

Her inquest has heard Miss Comer had been suffering from Body Dysmorphic Disorder - where a person spends a lot of time worrying about their appearance - and struggled with eating disorders and self-harming.

Miss Comer had moved from Berkshire to Worcestershire in 2018 and took an overdose in the past that kept her in a coma for three weeks, before recovering.

Miss Comer had eight care coordinators, who are there to support people with complex needs, and there had been five months in 2021 when she was without one.

The inquest had also heard that Miss Comer had been referred to The Priory for treatment for BDD in 2021.

But, it had emerged, her referral was paused by a senior clinician as she had thought Miss Comer did not meet the criteria for her place to be locally funded.

The clinician had not understood the place would be funded centrally through NHS England so the referral should not have been paused.

After this, family and friends had said Miss Comer was “confused” and had a “loss of hope”.

The coroner said the key factors of the number of care-coordinators, that the trust had not focused on BDD and her loss of hope after being told the referral had been paused had contributed to Miss Comer’s decision to take the overdose.

After the verdict, Liam Dolan, from the trust, answered questions on what steps had been taken to address the areas the coroner had raised concerns on.

Mr Dolan said, at the time, the lack of care coordinators had been due to sickness and the workload with care coordinators at the time dealing with 100 patients each.

He said care coordinators now had 20-25 patients each, below the national guideline of 30, and there was a better retention of staff.

Asked if the referral funding mistake could happen now he offered reassurance it wouldn’t.

Despite this, the coroner said he still wasn't satisfied and ordered the prevention of future deaths report to be completed.

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