NHS trust's processes 'inadequate' says Ipswich coroner

A coroner has deemed the processes of a mental health trust "inadequate".

Ellen Woolnough, 27, from Ipswich, had been under the care of Norfolk and Suffolk NHS Foundation Trust (NSFT) when she died in July 2022.

Dr Darren Stewart ruled her death a suicide, but raised concerns over NSFT's handling of her care and its subsequent investigation.

He said there had been a "missed opportunity" to engage with Ms Woolnough prior to her death.

Ms Woolnough, known as Ellie to friends and family, had struggled with her mental health since the age of six and was later diagnosed with emotionally unstable personality disorder.

On 20 July 2022, she attempted to take her own life and was subsequently admitted to hospital, where she died eight days later.

Suffolk Coroner's Court, Ipswich
Dr Darren Stewart described the NSFT's processes as "inadequate"

In a statement read by the coroner, Ellie's parents James and Lisa described her as a "very mature, caring, generous person that exuded warmth and charisma".

Her partner Chandler Newcombe added that she was "the most beautiful girl in the world", and said that Ellie was the "love of his life".

'Poor practice'

In May 2022, Ellie had met with the trust's Integrated Delivery Team before she was discharged following an unsuccessful second meeting.

Dr Stewart referred to this as a "failed interaction", and said it "constituted a missed opportunity to further engage with Ellie and arrange a follow-up meeting to provide general safety planning".

On 19 July, Ellie had received a four-minute triage call with the trust's Crisis Response Home Treatment Team.

"It is clear to me that there was ineffective risk management, and poor to non-existent safety planning that occurred during that call," said Dr Stewart.

The call handler downgraded Ellie's case from "emergency" to "urgent". The court heard how NSFT policy required approval from a secondary clinician before this step was taken, but this did not occur.

"The failure to retain that call and for it to be allowed to be deleted is, at best, poor practice which does not meet the trust's duty of candour to this court, let alone its ability to perform an effective and reflective investigation," added Dr Stewart.

'Listened carefully'

The coroner concluded that Ms Woolnough's death was the result of suicide. He said: "I am satisfied that there is sufficient evidence that Ellie intended to take her life."

Dr Steward will be completing a Prevention of Future Deaths report, which he said will be issued by the end of February.

Cath Byford, the deputy chief executive and chief people officer at NSFT, said: "We are very sorry for the distress that Ellen's tragic loss has caused and would like to offer our sincere condolences to her family.

"We have listened carefully to the concerns that were raised during the inquest and are determined to prevent a similar incident from happening again.

"It is clear that there was more we could - and should - have done to support Ellen in the weeks leading up to her death. We are already taking actions to improve, which include reviewing the processes in place to ensure safety when a patient leaves mid-way through an assessment.

"We have also introduced extra steps to make sure that relevant recordings of phone calls are retained to support the inquiries which take place at the inquest."


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