Source · Prevention of Future Deaths
Charlotte Werner
Ref: 2025-0270
Date: 2 Jun 2025
Coroner: Mary Hassell
Area: Inner North London
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner noted a potential misunderstanding regarding the scope of UCLH's dietetic service and suggested clarifying on its website or in correspondence that it is not a mental health service and does not treat eating disorders.
Date
2 Jun 2025
56-day deadline
28 Jul 2025 est.
estimated from the report date
Responses identified
0 of 1
Coroner's concerns
The coroner noted a potential misunderstanding regarding the scope of UCLH's dietetic service and suggested clarifying on its website or in correspondence that it is not a mental health service and does not treat eating disorders.
View full coroner's concerns
Charlotte’s mother formed the view that Charlotte was suffering from an eating disorder and was under the impression that the referral to a UCLH dietitian was made, at least in part, in order to explore this.
In fact, Charlotte was never diagnosed with an eating disorder, did not meet the criteria for a referral on this basis and was referred solely for consideration of whether her nutritional status was having an impact on her height.
I found no evidence of any link between Charlotte’s eating and her death. However, that might be different for another child.
It seems from the evidence I heard that an explanation, perhaps on the website or in correspondence, that the UCLH dietetic service is not a mental health service and does not treating eating disorders, could be helpful.
In fact, Charlotte was never diagnosed with an eating disorder, did not meet the criteria for a referral on this basis and was referred solely for consideration of whether her nutritional status was having an impact on her height.
I found no evidence of any link between Charlotte’s eating and her death. However, that might be different for another child.
It seems from the evidence I heard that an explanation, perhaps on the website or in correspondence, that the UCLH dietetic service is not a mental health service and does not treating eating disorders, could be helpful.
Report sections
Investigation and inquest
On 29 November 2024, one of my assistant coroners, Richard Brittain, commenced an investigation into the death of Charlotte Louise Werner, aged 13 years. The investigation concluded at the end of the inquest on 28 May 2025. I made a determination at inquest of death by suicide.
Circumstances of the death
Charlotte hanged herself at home.
Similar PFD reports
Report details
- Reference
- 2025-0270
- Date of report
- 2 June 2025
- Coroner
- Mary Hassell
- Coroner area
- Inner North London
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 28 Jul 2025 (estimated from the report date).
Sent to
- University College London Hospitals NHS Trust