Charlotte Werner

Medical Director University College London Hospitals NHS Trust (UCLH)

I am: Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Poplar Coroner’s Court Bow Coroner’s Court

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.

Charlotte hanged herself at home.

During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 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 my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action.