Trust's apology as coroner rules Earls Croome woman died of overdose - The Evesham Observer

Trust's apology as coroner rules Earls Croome woman died of overdose

Evesham Editorial 3rd Mar, 2023   0

A GRIEVING family have spoken of the ‘wonderful friend, sister, daughter, and aunt with the biggest heart’.

Charlotte Comer’s family spoke as a coroner ruled the 30-year-old from Worcestershire died following an overdose.

During a week-long inquest at Stourport Coroners Court, Worcestershire’s senior coroner David Reid said Charlotte died with her family by her bedside at the Worcestershire Royal Hospital in July 2021.

‘Gross failures’ in her care for mental health conditions including Body Dysmorphic Disorder (BDD) were also recorded by Mr Reid.

Speaking before the verdict, her family spoke of Charlotte’s suffering for several years following bullying at school and said she had repeatedly sought specialist medical help for her BDD.




Charlotte’s sister Mo Knight Evans, said: “Charlotte was articulate and intelligent. She was more than aware of the significant impact that BDD was having on her life.

“Over the years, Charlotte diligently researched her symptoms and was convinced she needed a referral for specialist BDD treatment.


“She knew The Priory offered the care and support she needed, but the NHS failed her. The NHS did not refer her to The Priory and crucially, could not properly manage her expectations.

“Charlotte went to great lengths to tell every single member of every care team she met the extent of her condition and its devastating impact on her life. She battled so hard to be understood, fight her BDD and get the specialist care she desperately needed. But it was not forthcoming.

“One of Charlotte’s last wishes, before she died, was to ‘make a noise’ so that others diagnosed with BDD do not suffer in the same way that unfortunately had.”

“Charlotte was deeply loved by everyone lucky enough to know her. She was a wonderful friend, sister, daughter, and aunt with the biggest heart.

“She was a nanny and loved working with children with additional needs at Manor Green School. She had trained to be a paediatric nurse, and just before her death, she was working as a physiotherapy assistant at the Worcestershire Royal Hospital.

“Her biggest passion was volunteering with her therapy dog Erin at Great Ormond Street Hospital. We all miss her desperately, and our lives, while enriched for knowing her, will never be the same.”

Specialist solicitor from Novum Law, Rhiannon Davies, who represents Charlotte’s family, said: “We hope out of this comes more awareness and greater understanding – both in the healthcare sector and the public – about the distress, despair, and feelings of hopelessness that Body Dysmorphic Disorder can cause.

“When someone with BDD asks for help, they must have access to specialist treatment that will make a difference and help them get better.

“Charlotte’s loss of hope as a result of the blocked referral caused her mental health to spiral and led to her sad death.”

A STATEMENT from Herefordshire and Worcestershire Health and Care NHS Trust said: “We accept the coroner’s findings and apologise unreservedly to Charlotte’s family and friends for the failings identified at the inquest which may have contributed to her death.

“Following an internal review we have introduced new processes for funding arrangements and made significant changes to the structure of the care coordinator role.

“As a result, care coordinator caseload sizes are now always within the national guidelines.

“We have also seen an increase in staff retention, with patients now supported by a consistent care coordinator or key worker who is familiar with their care.

“While we deeply regret the failings in Charlotte’s case, it is important that anyone in Herefordshire and Worcestershire struggling with their mental health continues to access the support available locally.

“This includes help with common symptoms such as depression and anxiety, more specialist support for complex conditions, and urgent help for anyone experiencing a mental health crisis.”

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