A coroner has criticised that crucial evidence is missing into the death of a young woman from Ipswich, while her family say the mental health trust who cared for her were “Machiavellian” and “a law until themselves”.

On Friday, an inquest resumed into the death of Ellen Woolnough from Ipswich, known as Ellie to her family and friends, who died aged 27 in July 2022.

Miss Woolnough had struggled with her mental health since the age of six. She was diagnosed with Emotionally Unstable Personality Disorder, and was under the care of the Norfolk and Suffolk NHS Foundation Trust (NSFT) at the time of her death.

In court on Friday were Miss Woolnough’s parents, Lisa and James Woolnough, and her partner, CJ Newcombe.

In a statement read by Mrs Woolnough, she told the court how she and her husband have spent “hundreds of hours” pouring over documents and notes in preparation for this inquest, determined as they were to do this “one last thing for Ellie”.

“All this time could have been better spent grieving our girl,” said Mrs Woolnough.

During this time, they said that NSFT had been “a law unto themselves” in not providing evidence or doing so more than six months after it had been requested.

“NSFT needs to start listening to the voice of the person who is using their service,” Mrs Woolnough continued.

She asked the presiding coroner Mr Darren Stewart OBE to consider the missed opportunities identified during her daughter’s inquest, and said that her family would like to see NSFT develop a “less Machiavellian attitude to the inquest process”.

Ipswich Star: An inquest into Miss Woolnough's death is currently underway at Suffolk Coroners' Court in Ipswich. Image: NewsquestAn inquest into Miss Woolnough's death is currently underway at Suffolk Coroners' Court in Ipswich. Image: Newsquest (Image: Newsquest)

Miss Woolnough had received two calls from a mental health nurse from NSFT’s crisis team at 5:31pm on July 19, the day before she was found at home by her family.

It is NSFT’s policy that ‘urgent’ calls such as this are assessed within four hours, the call handler, Miss Sarah Gifford, had arranged with Miss Woolnough that she would be seen at 11am the next day.

Owing to staff sickness, the earliest the team could visit Miss Woolnough would have been midnight, and Miss Gifford felt that it would be preferable to visit Miss Woolnough in the morning, as she was suffering from a vomiting bug at the time.

NSFT’s recording of this call, which presiding coroner Mr Darren Stewart OBE has described as “crucial” to his investigation, was destroyed by the Trust.

Ipswich Star: Mr Steward has said that he will be writing to Caroline Donovan, NSFT's chief. (Image: NSFT)Mr Steward has said that he will be writing to Caroline Donovan, NSFT's chief. (Image: NSFT) (Image: NSFT)

Over the course of the inquest, the court has heard that all calls are recorded, but that these recordings are retained for one month only and that this call was not identified as needing to be saved.

Miss Woolnough’s family have provided their own recordings of the calls, which were made using an app on Miss Woolnough’s mobile phone. However, only Miss Woolnough’s side of the conversation is audible.

Mr Stewart expressed his concerns that NSFT had not kept the recordings as evidence, given that it was made aware on the morning of July 20 that Miss Woolnough was in hospital following a serious incident.

“I find it breathtaking that the Trust seems to think that isn’t a problem,” he said. “I find it difficult to understand how in those circumstances that recording was not kept.”

NSFT’s legal representative argued that evidence had been submitted in the form of three statements written by Miss Gifford and oral evidence she submitted in court.

However, Mr Stewart said that he had doubts regarding the credibility of Miss Gifford’s statements, given that they were collected several months after the incident, and the fact that she said she struggled to recall the calls.

He described her evidence as having “more holes than Swiss cheese”.

The inquest is expected to conclude on February 13.