Drug service changes after coroner warning over Carlisle man's death

Summarised from 3 outlets · Updated 10 Nov, 10:28 · Archive

A drug and alcohol support service is changing how it shares information with mental health teams after a coroner warned of risks following a man's death.

Graeme John Wear Elliott, 38, was found dead in a Carlisle hotel on 17 October 2025. His family described him as a 'loved' son, loyal brother, devoted uncle and treasured grandson, saying his death had 'left a hole in the lives of many'.

Area Coroner Margaret Taylor issued a Prevention of Future Deaths report after hearing that Mr Elliott had disclosed information about how he might take his own life during an appointment with Recovery Steps Cumbria on 9 October, eight days before his death. The information was not passed to the mental health team already supporting him. Ms Taylor said this led to a 'missed opportunity' for other agencies to review his risk to himself.

Waythrough, which operates Recovery Steps Cumbria, issued a detailed response explaining its actions. During Mr Elliott's first assessment on 9 October, there had been a full discussion about his mental health. According to the service's statement, Mr Elliott said he was not experiencing suicidal thoughts and scored his mental health as 18/20. He spoke about a previous suicide attempt by overdose and described how, if his mental health deteriorated in the future, he would end his life. The service said this was not a current plan or intention and that he was clear he was not experiencing suicidal thoughts at the time.

Waythrough said a safety plan was discussed and Mr Elliott's risk of harm to himself was assessed as low, although he was given a Red rating requiring more frequent contact. The service has now changed the way it shares information with mental health teams in response to the coroner's concerns.

How it is being reported

• Coroner warning prompts service changes after death of ‘loved’ man, 38A service is changing how it shares information with mental health teams after a coroner raised concerns following the death of a Carlisle man, 38.NW Evening Mail · 10 Nov, 10:13
• Coroner warning prompts service changes after death of ‘loved’ man, 38A service is changing how it shares information with mental health teams after a coroner raised concerns following the death of a Carlisle man, 38.Westmorland Gazette · 10 Nov, 10:13
• Coroner warning prompts service changes after death of ‘loved’ man, 38A service is changing how it shares information with mental health teams after a coroner raised concerns following the death of a Carlisle man, 38.News & Star · 10 Nov, 05:00

In this story: Graeme John Wear Elliott · Margaret Taylor · Recovery Steps Cumbria · Waythrough · Carlisle

This summary was written by AI from the headlines and standfirsts above, and states as fact only what at least two outlets report. How we use AI · Report a problem · Corrections log