Mental health advocates say lessons should have been learned before the death of a young woman from Ipswich, while the trust that supported her said it is taking steps to improve.

On Tuesday, the inquest into the death of Ellen Woolnough from Ipswich reached its conclusion.

Miss Woolnough, 27, had struggled with her mental health since the age of six, and was under the care of the Norfolk and Suffolk NHS Foundation Trust (NSFT) at the time of her death in July 2022.

The coroner ruled on Tuesday that Miss Woolnough had taken her own life while struggling with the diagnosed condition of Emotionally Unstable Personality Disorder.

Over the course of the inquest, it was heard that Miss Woolnough had an unsuccessful visit with NSFT's Integrated Delivery Team in May.

She left the appointment abruptly after becoming upset and “triggered”, and the decision was made to discharge her without any follow-up.

Miss Woolnough’s father, James Woolnough, is a mental health advocate for the Suffolk User Forum, based in Kesgrave.

The organisation strives to be a voice for those using mental health services in our county.

SUF has now released a joint statement on behalf of Mr Woolnough, chief officer Jayne Stevens and the rest of SUF’s staff and trustees.

Miss Woolnough’s death was, they said, “such an awful but too familiar story of personal struggle, missed opportunities, failures by NSFT and the sad consequence for Ellie, her family, friends and those who knew her”.

It continued: “There is little from Ellie’s death which NSFT should not have learned previously, from previous deaths, previous prevention of future deaths notices and from our continuous feedback.

“We understand the frustration, loss of confidence and anger that many now experience, fearful as to whether you or your loved ones, friends or family are receiving the right care, at the right time and from the right person.”

Ipswich Star: Jayne Stevens is the chief officer at the Suffolk User Forum, which strives to be a voice for mental health service users. Image: SUFJayne Stevens is the chief officer at the Suffolk User Forum, which strives to be a voice for mental health service users. Image: SUF (Image: Suffolk User Forum)

The statement said that SUF will continue to “robustly challenge” NSFT, and concluded by emphasising that the organisation will always strive to champion the best interests of mental health service users.

Cath Byford is deputy chief executive and chief people officer at NSFT.

She said: “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.

“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."

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.