Hollie Loraine

I am David Place, His Majesty’s Senior Coroner for the City of Sunderland

On 10 th April 2025 I commenced an Investigation into the death of Hollie Elizabeth Loraine, who died in Washington on 30 th August 2025 aged 27 years. The Investigation concluded at the end of the Inquest on 27 th March 2026. The medical cause of death was confirmed as: – Pressure to the neck Hanging Alcohol Intoxication I gave a conclusion of Misadventure.

Hollie Elizabeth Loraine had a long history of mental health concerns compounded at times by her use of alcohol in binge patterns and included suicidal ideation and numerous previous attempts to  end her life. She died at her home address in Washington, Sunderland on 30 th August 2025 by  hanging from the loft hatch using a ligature made from a dressing gown belt having consumed a  large quantity of alcohol in the period leading up to her death which was found to be at a level  which, on the balance of probabilities, is likely to have significantly affected her state of mind.

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: On the day of her death, Hollie telephoned the North East Ambulance Service NHS Foundation  Trust’s 111 service at 05.22 hours. Hollie indicated that she was feeling suicidal and had made her  mind up over the last 5 days. She stated that she had a noose around her neck and was about to  jump. She added that she did not need an ambulance but needed someone to cut her down. Later in the call she said that she would get herself down. The call handler confirmed that an ambulance was in place. Hollie then referred to having a team involved with her but that whilst it was helping  it didn’t change the situation. The call handler reassured Hollie that help was in place for her 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. The evidence revealed that the call handler was following the national NHS pathways system and  Hollie was considered as requiring a category 3 response in accordance with the pathway. This was correctly upgraded by a clinician following a review. The first ambulance crew arrived at Hollie’s location at 06.17 and she could not be revived.  Hollie’s call to the service had ended at 05.31 but she did not respond to attempts by a clinician to call her back at 05.40, 05.43 and 05.45. 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. Hollie made it clear  she had a noose around her neck and was going to jump. I shall be glad to be told of any learning arising from his death and timescales and results of your review.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.