Recovery Steps Cumbria
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Dear Miss Gomersal,
Re: Waythrough’s response in regard to the Regulation 28, following the Inquest into the late Charlotte Jones
I write in response to your Regulation 28 Report to Prevent Future Deaths dated 11 March 2026 concerning the death of Charlotte Louise Jones on 10 February 2025. I respond on behalf of Waythrough, which operates Recovery Steps Cumbria (“RSC”).
Waythrough has carefully considered the matters of concern set out in your report. We wish to express our sincere condolences to Miss Jones’ family and friends for their loss. The death of any individual known to our services is treated with the utmost seriousness, and we have given detailed consideration to the concerns you have raised.
It is stated within your findings that whilst RSC and Cumbria Northumberland Tyne and Wear NHS Foundation Trust ("CNTW") have procedures by which information about service users is shared, those procedures are not yet appropriate to ensure adequate exchange of information about service users whether or not the service user has been accepted onto a particular treatment pathway.
Context of Service
Before addressing the specific concern, it may assist the Court to understand the context of the service provided by RSC. RSC is a specialist drug and alcohol recovery service for adults over the age of 18 who have an identified alcohol or drug need and who reside in Cumbria. The service is 100% funded by the local authority through public health teams. Engagement with the service is voluntary and those accessing the service have the option to consent or decline whether information about their care is shared with other agencies. RSC is delivered by Waythrough and operates a person-centred, recovery-oriented model underpinned by trauma- informed practice, delivering inclusive support pathways tailored to individuals' specific needs and varied goals.
Registered address: Inspiration House, Unit 22, Bowburn North Industrial Estate DH6 5PF. Waythrough Charity (Waythrough) is a company registered in England (Registered Charity
No. 515755 Registered Company No 182 0492, VAT 413 2088 32, Registered Provider 4713)
RSC operates three primary treatment pathways: an opioid pathway, an alcohol pathway, and a non-opioid and non-dependent alcohol pathway. Charlotte was supported on the non-opioid and non-dependent alcohol pathway. Under this pathway, the prescribed intervention follows a structured programme of approximately 12 sessions, progressing through engagement and building motivation for change, to addressing triggers, high-risk situations and coping skills, and then to lapse/relapse prevention and forward planning. Harm reduction information and psychosocial interventions, delivered with a trauma-informed approach, are provided throughout the treatment journey.
In addition to primary appointments, individuals have access to drop-in sessions and group work. Charlotte engaged meaningfully with these services and participated actively in group sessions, demonstrating openness and honesty in those settings. In working with Charlotte, RSC also focused on meaningful activities and wider social circumstances as part of her recovery planning. Where RSC identifies that another agency is involved with an individual, it considers whether joint working is required, and there is good evidence of collaborative working with Probation in Charlotte's case.
RSC and CNTW have a Co-occurring Mental Health and Substance Use Joint Working Protocol that is operational. The purpose of this is to ensure that recovery centred asset-based care is in place for individuals with a co-occurring need, and to ensure that true cohesion and dovetailing of the co-occurring agenda is adopted and applied consistently and effectively in practice to all in North Cumbria.
The Support Provided to Charlotte
To provide context for the Coroner's concern, it is relevant to set out the nature and extent of RSC's involvement with and support of Charlotte.
Charlotte had been known to addiction services in Cumbria for several years. Her last episode of support commenced in August 2023, when she was referred to the service by Probation for support in relation to her alcohol use. Charlotte presented with co-occurring needs, including emotional difficulties and previous trauma, alongside periods of increased alcohol use. RSC utilised validated screening instruments including the GAD-7 (generalised anxiety disorder self- assessment tool) and physical health screening tools to identify and monitor any mental health needs, making onward referrals where appropriate.
RSC continued to work with Charlotte on an ongoing basis, including during periods of relative stability when she was not turning to alcohol. Although consideration was given to discharge at points where Charlotte had completed the interventions RSC could offer, the service continued to work with her given her fluctuating circumstances.
In the period leading up to Charlotte's death, RSC maintained regular contact with her, conducted internal case discussions, liaised with relevant agencies including the police, probation, housing, and hospital services, and escalated concerns where appropriate.
During Charlotte’s engagement with RSC, the service referred her to the CNTW Community Treatment Team on a number of occasions and also kept in touch with CNTW to ascertain where Charlotte was on the waiting list.
Registered address: Inspiration House, Unit 22, Bowburn North Industrial Estate DH6 5PF. Waythrough Charity (Waythrough) is a company registered in England (Registered Charity
No. 515755 Registered Company No 182 0492, VAT 413 2088 32, Registered Provider 4713)
Multi-Agency Collaborative Working
RSC participated actively in multi-agency collaborative working in respect of Charlotte. For a period of approximately 12 weeks prior to Charlotte's death, multi-agency collaborative work was undertaken through the Local Focus Hub, a forum operated through Cumbria Police for anti-social behaviour concerns. This forum has sign-up from local agencies and provides a platform for agencies to coordinate their responses to individuals of concern. RSC attended those meetings and actively contributed to the planning and oversight of Charlotte's case within that forum.
It is important to note that the Local Focus Hub is not a statutory meeting, and attendance is voluntary, RSC's participation in that forum demonstrates good practice and reflects the willingness of local services to adapt their remit and collaborate to use their collective skillsets in the best interests of the individual.
The Existing Joint Working Protocol with CNTW
Since October 2023, there has been a Co-Occurring Mental Health and Substance Use Joint Working Protocol in place between RSC and CNTW. The purpose of this protocol is to ensure that recovery-centred, asset-based care is in place for individuals with a co-occurring need, and to ensure that true cohesion and dovetailing of the co-occurring agenda is adopted and applied consistently and effectively in practice to all in North Cumbria.
The key principles of the protocol include that service users should not be prevented from accessing a particular service due to substance use or severe mental health; that co-occurring conditions should be seen as the norm not the exception; and that a collaborative approach is required to meet such needs. The protocol also provides that where a service user is receiving care from both services, they will have a joint care plan and risk assessment, and that discharge from either service should be a discussed and planned process agreed through the wider MDT.
Under the protocol, monthly interface meetings are held between RSC and CNTW, with allocated time slots that can be booked by staff from either organisation. These sessions allow clinicians from both services to bring complex, co-occurring cases for discussion, and patients do not have to be accepted into a CNTW service to be discussed at these meetings.
Where an agreement cannot be reached between both services on a complex matter, each service has an escalation process.
Response to the Coroner's Concern
RSC alongside our colleagues from CNTW recognise and accept that there is an opportunity to collectively strengthen our partnership working. Following the matters of concern raised, immediate action was taken as follows:
1. A partnership meeting was held between RSC and CNTW to discuss the matters of concern, identify immediate actions, and create a longer-term plan for enhanced care
Registered address: Inspiration House, Unit 22, Bowburn North Industrial Estate DH6 5PF. Waythrough Charity (Waythrough) is a company registered in England (Registered Charity
No. 515755 Registered Company No 182 0492, VAT 413 2088 32, Registered Provider 4713)
delivery for individuals with co-occurring needs. An initial meeting took place on 15 April 2026, where actions were agreed to include a comparison between the current protocol and CNTW's organisational stance on co-occurring substances.
2. Creation and implementation of a working group to jointly review the co-occurring joint protocol has been initiated, which includes staff members from both organisations.
In addition, RSC has undertaken the following actions:
• A review of how mental health information is flagged and captured within RSC's clinical management system SystmOne has been undertaken, to ensure that mental health concerns and onward referrals are more prominently recorded and visible to all practitioners working with an individual.
• The addition of a mental health crisis referral as an incident category within The Hub, Waythrough's management of incidents system, to ensure that escalations relating to mental health crises are formally captured and tracked.
• A longer-term plan to re-launch a refreshed and updated co-occurring pathway across North Cumbria, initially with a view of rolling this out across the wider CNTW catchment. The protocol will include clear escalation routes, improved communication pathways between RSC and CNTW, and a formalised process for following up on onward referrals where a response has not been received within an agreed timeframe. CNTW and RSC are in the process of cooperatively reviewing the protocol in line with the following aims:
o The potential to apply the protocol across relevant departments, supporting a consistent approach and clear cross-team accountability;
o To confirm nominated leads within RSC and CNTW to review the operational elements of the protocol and ensure it is working effectively in practice;
o To review all single points of contact (SPOC) and referral information and ensure the relevant parties are updated;
o To invest in education and awareness-raising for frontline practitioners so the protocol is understood and implemented consistently;
o To improve the capture and documentation of information-sharing between RSC and CNTW, including acknowledgement of information received and clear, timely responses, to support proper record keeping;
o To strengthen joint care planning and risk assessment, using interface meetings to address escalating and unmitigated risks, and to ensure the protocol can accommodate an increased frequency of interface meetings, with a view to holding these on a weekly basis where clinically indicated.
Registered address: Inspiration House, Unit 22, Bowburn North Industrial Estate DH6 5PF. Waythrough Charity (Waythrough) is a company registered in England (Registered Charity
No. 515755 Registered Company No 182 0492, VAT 413 2088 32, Registered Provider 4713)
RSC is committed to the review of the joint working protocol with CNTW. RSC considers that the current period presents a timely opportunity to review how practitioners from both organisations work together, not solely as a result of Charlotte's case but more broadly in terms of how collaborative working can be strengthened for all individuals with co-occurring needs.
Conclusion
I hope that the above offers reassurance in respect of how Waythrough has responded to the issues you have raised. The care provided to Charlotte by RSC was delivered with compassion and dedication by practitioners who knew her well and worked tirelessly to support her during an exceptionally difficult period. RSC maintained contact with Charlotte, actively participated in multi-agency forums to coordinate her care, and escalated concerns to statutory services where appropriate.
Reducing drug and alcohol related deaths within the county is a priority for Waythrough, and we are committed to working collaboratively with all partner agencies to learn from and reduce the number of deaths in the area.
On behalf of all staff at RSC, I would like to pass our sincere condolences to Charlotte's family and friends.
Re: Waythrough’s response in regard to the Regulation 28, following the Inquest into the late Charlotte Jones
I write in response to your Regulation 28 Report to Prevent Future Deaths dated 11 March 2026 concerning the death of Charlotte Louise Jones on 10 February 2025. I respond on behalf of Waythrough, which operates Recovery Steps Cumbria (“RSC”).
Waythrough has carefully considered the matters of concern set out in your report. We wish to express our sincere condolences to Miss Jones’ family and friends for their loss. The death of any individual known to our services is treated with the utmost seriousness, and we have given detailed consideration to the concerns you have raised.
It is stated within your findings that whilst RSC and Cumbria Northumberland Tyne and Wear NHS Foundation Trust ("CNTW") have procedures by which information about service users is shared, those procedures are not yet appropriate to ensure adequate exchange of information about service users whether or not the service user has been accepted onto a particular treatment pathway.
Context of Service
Before addressing the specific concern, it may assist the Court to understand the context of the service provided by RSC. RSC is a specialist drug and alcohol recovery service for adults over the age of 18 who have an identified alcohol or drug need and who reside in Cumbria. The service is 100% funded by the local authority through public health teams. Engagement with the service is voluntary and those accessing the service have the option to consent or decline whether information about their care is shared with other agencies. RSC is delivered by Waythrough and operates a person-centred, recovery-oriented model underpinned by trauma- informed practice, delivering inclusive support pathways tailored to individuals' specific needs and varied goals.
Registered address: Inspiration House, Unit 22, Bowburn North Industrial Estate DH6 5PF. Waythrough Charity (Waythrough) is a company registered in England (Registered Charity
No. 515755 Registered Company No 182 0492, VAT 413 2088 32, Registered Provider 4713)
RSC operates three primary treatment pathways: an opioid pathway, an alcohol pathway, and a non-opioid and non-dependent alcohol pathway. Charlotte was supported on the non-opioid and non-dependent alcohol pathway. Under this pathway, the prescribed intervention follows a structured programme of approximately 12 sessions, progressing through engagement and building motivation for change, to addressing triggers, high-risk situations and coping skills, and then to lapse/relapse prevention and forward planning. Harm reduction information and psychosocial interventions, delivered with a trauma-informed approach, are provided throughout the treatment journey.
In addition to primary appointments, individuals have access to drop-in sessions and group work. Charlotte engaged meaningfully with these services and participated actively in group sessions, demonstrating openness and honesty in those settings. In working with Charlotte, RSC also focused on meaningful activities and wider social circumstances as part of her recovery planning. Where RSC identifies that another agency is involved with an individual, it considers whether joint working is required, and there is good evidence of collaborative working with Probation in Charlotte's case.
RSC and CNTW have a Co-occurring Mental Health and Substance Use Joint Working Protocol that is operational. The purpose of this is to ensure that recovery centred asset-based care is in place for individuals with a co-occurring need, and to ensure that true cohesion and dovetailing of the co-occurring agenda is adopted and applied consistently and effectively in practice to all in North Cumbria.
The Support Provided to Charlotte
To provide context for the Coroner's concern, it is relevant to set out the nature and extent of RSC's involvement with and support of Charlotte.
Charlotte had been known to addiction services in Cumbria for several years. Her last episode of support commenced in August 2023, when she was referred to the service by Probation for support in relation to her alcohol use. Charlotte presented with co-occurring needs, including emotional difficulties and previous trauma, alongside periods of increased alcohol use. RSC utilised validated screening instruments including the GAD-7 (generalised anxiety disorder self- assessment tool) and physical health screening tools to identify and monitor any mental health needs, making onward referrals where appropriate.
RSC continued to work with Charlotte on an ongoing basis, including during periods of relative stability when she was not turning to alcohol. Although consideration was given to discharge at points where Charlotte had completed the interventions RSC could offer, the service continued to work with her given her fluctuating circumstances.
In the period leading up to Charlotte's death, RSC maintained regular contact with her, conducted internal case discussions, liaised with relevant agencies including the police, probation, housing, and hospital services, and escalated concerns where appropriate.
During Charlotte’s engagement with RSC, the service referred her to the CNTW Community Treatment Team on a number of occasions and also kept in touch with CNTW to ascertain where Charlotte was on the waiting list.
Registered address: Inspiration House, Unit 22, Bowburn North Industrial Estate DH6 5PF. Waythrough Charity (Waythrough) is a company registered in England (Registered Charity
No. 515755 Registered Company No 182 0492, VAT 413 2088 32, Registered Provider 4713)
Multi-Agency Collaborative Working
RSC participated actively in multi-agency collaborative working in respect of Charlotte. For a period of approximately 12 weeks prior to Charlotte's death, multi-agency collaborative work was undertaken through the Local Focus Hub, a forum operated through Cumbria Police for anti-social behaviour concerns. This forum has sign-up from local agencies and provides a platform for agencies to coordinate their responses to individuals of concern. RSC attended those meetings and actively contributed to the planning and oversight of Charlotte's case within that forum.
It is important to note that the Local Focus Hub is not a statutory meeting, and attendance is voluntary, RSC's participation in that forum demonstrates good practice and reflects the willingness of local services to adapt their remit and collaborate to use their collective skillsets in the best interests of the individual.
The Existing Joint Working Protocol with CNTW
Since October 2023, there has been a Co-Occurring Mental Health and Substance Use Joint Working Protocol in place between RSC and CNTW. The purpose of this protocol is to ensure that recovery-centred, asset-based care is in place for individuals with a co-occurring need, and to ensure that true cohesion and dovetailing of the co-occurring agenda is adopted and applied consistently and effectively in practice to all in North Cumbria.
The key principles of the protocol include that service users should not be prevented from accessing a particular service due to substance use or severe mental health; that co-occurring conditions should be seen as the norm not the exception; and that a collaborative approach is required to meet such needs. The protocol also provides that where a service user is receiving care from both services, they will have a joint care plan and risk assessment, and that discharge from either service should be a discussed and planned process agreed through the wider MDT.
Under the protocol, monthly interface meetings are held between RSC and CNTW, with allocated time slots that can be booked by staff from either organisation. These sessions allow clinicians from both services to bring complex, co-occurring cases for discussion, and patients do not have to be accepted into a CNTW service to be discussed at these meetings.
Where an agreement cannot be reached between both services on a complex matter, each service has an escalation process.
Response to the Coroner's Concern
RSC alongside our colleagues from CNTW recognise and accept that there is an opportunity to collectively strengthen our partnership working. Following the matters of concern raised, immediate action was taken as follows:
1. A partnership meeting was held between RSC and CNTW to discuss the matters of concern, identify immediate actions, and create a longer-term plan for enhanced care
Registered address: Inspiration House, Unit 22, Bowburn North Industrial Estate DH6 5PF. Waythrough Charity (Waythrough) is a company registered in England (Registered Charity
No. 515755 Registered Company No 182 0492, VAT 413 2088 32, Registered Provider 4713)
delivery for individuals with co-occurring needs. An initial meeting took place on 15 April 2026, where actions were agreed to include a comparison between the current protocol and CNTW's organisational stance on co-occurring substances.
2. Creation and implementation of a working group to jointly review the co-occurring joint protocol has been initiated, which includes staff members from both organisations.
In addition, RSC has undertaken the following actions:
• A review of how mental health information is flagged and captured within RSC's clinical management system SystmOne has been undertaken, to ensure that mental health concerns and onward referrals are more prominently recorded and visible to all practitioners working with an individual.
• The addition of a mental health crisis referral as an incident category within The Hub, Waythrough's management of incidents system, to ensure that escalations relating to mental health crises are formally captured and tracked.
• A longer-term plan to re-launch a refreshed and updated co-occurring pathway across North Cumbria, initially with a view of rolling this out across the wider CNTW catchment. The protocol will include clear escalation routes, improved communication pathways between RSC and CNTW, and a formalised process for following up on onward referrals where a response has not been received within an agreed timeframe. CNTW and RSC are in the process of cooperatively reviewing the protocol in line with the following aims:
o The potential to apply the protocol across relevant departments, supporting a consistent approach and clear cross-team accountability;
o To confirm nominated leads within RSC and CNTW to review the operational elements of the protocol and ensure it is working effectively in practice;
o To review all single points of contact (SPOC) and referral information and ensure the relevant parties are updated;
o To invest in education and awareness-raising for frontline practitioners so the protocol is understood and implemented consistently;
o To improve the capture and documentation of information-sharing between RSC and CNTW, including acknowledgement of information received and clear, timely responses, to support proper record keeping;
o To strengthen joint care planning and risk assessment, using interface meetings to address escalating and unmitigated risks, and to ensure the protocol can accommodate an increased frequency of interface meetings, with a view to holding these on a weekly basis where clinically indicated.
Registered address: Inspiration House, Unit 22, Bowburn North Industrial Estate DH6 5PF. Waythrough Charity (Waythrough) is a company registered in England (Registered Charity
No. 515755 Registered Company No 182 0492, VAT 413 2088 32, Registered Provider 4713)
RSC is committed to the review of the joint working protocol with CNTW. RSC considers that the current period presents a timely opportunity to review how practitioners from both organisations work together, not solely as a result of Charlotte's case but more broadly in terms of how collaborative working can be strengthened for all individuals with co-occurring needs.
Conclusion
I hope that the above offers reassurance in respect of how Waythrough has responded to the issues you have raised. The care provided to Charlotte by RSC was delivered with compassion and dedication by practitioners who knew her well and worked tirelessly to support her during an exceptionally difficult period. RSC maintained contact with Charlotte, actively participated in multi-agency forums to coordinate her care, and escalated concerns to statutory services where appropriate.
Reducing drug and alcohol related deaths within the county is a priority for Waythrough, and we are committed to working collaboratively with all partner agencies to learn from and reduce the number of deaths in the area.
On behalf of all staff at RSC, I would like to pass our sincere condolences to Charlotte's family and friends.