A coroner has said he is “flabbergasted” at the way a mental health trust investigated the death of a young woman from Ipswich. 

On the third day of an inquest into the death of Ellen Woolnough, presiding coroner Darren Stewart OBE told the court NSFT’s conduct had been “totally unsatisfactory”.

The inquest is expected to conclude on Friday.

Miss Woolnough, who was known to her family and friends as Ellie, was found by her family at home on July 20 2022. She died a week later in hospital on July 28.

Miss Woolnough had been diagnosed with Emotionally Unstable Personality Disorder, (EUPD), and was under the care of Norfolk and Suffolk NHS Foundation Trust (NSFT) at the time of her death.

She had been in contact with the trust's crisis team on July 19. 

Recordings of a call Miss Woolnough had with crisis mental health nurse Sarah Gifford on July 19 were not obtained, which Mr Stewart said amounted to a loss of “key evidence”.

Although NSFT were made aware of Miss Woolnough’s condition on the morning of July 20 when she arrived in hospital.

The court heard Miss Gifford was not informed until some weeks later, and a statement was not collected from her for another eight months.

Ipswich Star: The coroner said he would be writing to Caroline Donovan, NSFT's chief. (Image: NSFT)The coroner said he would be writing to Caroline Donovan, NSFT's chief. (Image: NSFT) (Image: NSFT)

Questions had been raised during the inquest if an investigation had been carried out at all.

Mr Stewart concluded that some investigation had taken place, but that this most likely happened “at best, four days after Ellie’s death and two weeks after the incident”.

In reading NSFT’s policies on investigating serious incidents, he said there were “significant contradictions which give rise to confusion”.

“I’m flabbergasted at the approach that has been adopted by the Trust,” he said.

“I have deep concerns about an incoherence in the Trust’s policy structure in dealing with these matters.”

He added that NSFT’s conduct had been “totally unsatisfactory”, and that he would be writing to NSFT’s chief executive and the Department of Health and Social Care regarding these failings.

On Tuesday, the court heard evidence from Miss Gifford, who called Miss Woolnough at 5:31pm the day before she is believed to have taken her own life.

Miss Gifford arranged for Miss Woolnough to receive a visit from the crisis team at 11am the following morning, as the earliest a same-day visit could take place would have been midnight owing to staff sickness.

Given that Miss Woolnough was suffering from a vomiting bug, Miss Gifford felt that this was the best solution.

Giving evidence on Wednesday was expert witness Dr Laurence Mynors-Wallis, a consultant psychiatrist.

He said that, although Miss Gifford’s four-minute phone call seemed brief, he believes that she was correct in her assessment that it was preferable to offer Miss Woolnough a visit with the Crisis at 11am the next day.

Carrying out mental health assessments during the night or early hours of the morning was, he said, “rarely helpful”.

He told the court: “If Miss Gifford had come and discussed the case with me and I was the consultant, I would have said this was a good response.

“If you stopped the story here, with Miss Gifford offering her an appointment the next day, I think almost everyone would expect Miss Woolnough to have gone to that appointment the next morning.”

In closing proceedings for the day, Mr Stewart offered his compliments to Miss Woolnough's parents, James and Lisa Woolnough, who he said had done a "remarkable, admirable job" in advocating for their daughter during her life, and continuing to do so after her death.