The family of a young woman from Ipswich who died aged 27 say they feel they can now “bring her home”, as the inquest into her death concludes.

An inquest has been underway since January into the death of Ellen Ocean Woolnough, who was known to her family and friends as Ellie.

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

In the months leading up to her death, Miss Woolnough had direct contact with NSFT on several occasions.

She had received a visit from the Crisis team in May, which was followed up with an unsuccessful visit with the Integrated Delivery Team.

Miss Woolnough left the appointment after feeling triggered by the questions put to her, and the decision was made to discharge her without follow-up.

On July 19, Miss Woolnough’s father contacted her GP after growing concerned for her welfare, who referred her once more to the crisis team.

Miss Woolnough received two calls from the crisis team at 5.31pm on July 19.

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.

However, this 11am visit never came to fruition. Miss Woolnough’s father and partner grew concerned after receiving worrying phone calls and texts from her.

They arrived at her apartment as quickly as they could on the morning of July 20, and found her inside. 

Miss Woolnough died in intensive care eight days later on July 28.

On Tuesday, presiding coroner Mr Darren Stewart OBE brought the inquest to a close.

He read from a statement given by Miss Woolnough’s partner, CJ Newcombe.

In it, Mr Newcombe described her as “the most beautiful girl in the world”. He recalled that Miss Woolnough would offer help to anyone who needed it, stepping in when she saw other people being bullied without a thought for herself.

She was, he said, the best person in the world, and the person he ought to have spent the rest of his life with.

Mr Stewart said that, on the balance of probabilities he could not say for sure that Miss Woolnough’s interactions with NSFT on May 20 or July 19 directly led to her death.

However, he did find that both interactions had been “inadequate” and “missed opportunities” to productively engage with Miss Woolnough.

He also again expressed frustration that NSFT had not retained recordings of Miss Woolnough’s phone calls with Miss Gifford.

“The failure to retain that call and allow it 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 form an effective and appropriately reflective response,” he said.

He noted that some improvements had been made, but that as yet these had not all been implemented.

He added that he would be writing a Prevention of Future Deaths Report regarding NSFT’s conduct.

Mr Stewart recorded a narrative conclusion, and found that Miss Woolnough had taken her own life while suffering the diagnosed condition of EUPD.

Speaking at the end of proceedings, Miss Woolnough’s parents said they wished that EUPD could be better understood and viewed without stigma.

“She just wanted to live a normal life,” said her mother, Lisa Woolnough.

The ordeal of having to relive everything their daughter had gone through had, her parents said, “put a kink in our grieving”.

However, they were relieved that the inquest process has ended.

“I feel I can bring her home now,” said Mrs Woolnough.

They said there were not interested in receiving sympathy from NSFT, who they had previously described as "Machiavellian" and "a law unto themselves".

“I don’t want their sympathy – they should take their sympathy and turn it into empathy for the next kids who are coming through their doors,” said Mrs Woolnough.

If you need urgent mental health support call NHS 111 and select option 2, or the Samaritans on 116 123. Both services are available 24 hours 7 days a week