Overview

• North Yorkshire coroner Catherine Cundy delivered a narrative conclusion that Victoria Taylor died by drowning, with her intention at the time remaining unclear.
• Ms Cundy said she will write to Tees, Esk and Wear Valleys NHS Foundation Trust and other agencies with prevention-of-future-deaths concerns about the care provided.
• Evidence detailed at the inquest showed CCTV tracked Taylor in Malton on 30 September 2024 and personal items were found by the River Derwent, where her body was recovered on 22 October after extensive searches.
• The inquiry heard crisis teams repeatedly assessed there was “no role” for secondary mental-health services despite serious incidents in 2024, including a river rescue in July and an overdose in August, with signposting to AA or private therapy instead of trauma-focused support.
• Taylor’s family said services failed her repeatedly and called for systemic change, while TEWV said it had reviewed the case, made service changes and will respond to the coroner’s report.