Woman's death prompts triage system concerns
GoogleThe death of a woman with a history of suicide attempts raises concerns over guidance in the national NHS pathways telephone triage system, a coroner has said.
Hollie Loraine died in Washington on 30 August 2025, having called 111 the same day and reporting she was feeling suicidal.
Sunderland's senior coroner David Place said the current triage system provided "no guidance" to health advisers over whether to continue the call and how to reduce risks for the patient in such cases.
NHS England has been contacted for a comment.
A document published by the coroner on Friday, known as a prevention of future deaths report, said Loraine had a history of attempting suicide and mental health concerns.
The report said this had at times been compounded by her "use of alcohol in binge patterns".
The 27-year-old had consumed a large quantity of alcohol in the period leading up to her death which had likely "significantly affected her state of mind", the coroner said.
'Told to ring back'
Loraine called 111 at 05:22 on the day of her death and said she was feeling suicidal, before describing the intended method to the advisor.
She said she did not need an ambulance but someone to help her end the attempt.
Loraine later said she would stop and the advisor confirmed an ambulance was in place.
They reassured her there was help and confirmed that the door to the property was open.
"The call handler then said, 'I can let you go now that I've got that help in place, is that alright?' Hollie said thank you and, after being told to ring back if her condition got worse or had new symptoms, Hollie ended the call," said the coroner's report.
The call ended at 05:31 and Loraine did not respond to a clinician's calls at 05:40, 05:43 and 05:45.
An ambulance arrived at 06:17 but she could not be revived.
'No guidance'
According to evidence, the call handler was following the national NHS pathways system and Loraine was considered as requiring a category 3 response.
This was correctly upgraded by a clinician following a review.
Place said Loraine had made it clear she was intending to end her life.
He said: "I am concerned that the evidence revealed that the national NHS pathways telephone triage system provides no guidance to health advisers dealing with such calls about whether to maintain telephone contact with a patient who is clearly expressing suicidal intent and, if maintaining contact, how to do so to ameliorate a risk of that patient ending their own life."
NHS England has 56 days to respond to the coroner's concerns and outline any action.
If you have been affected by any of the issues raised in this article, help is available from the BBC's Action Line.
