The coroner who investigated the death of a vulnerable woman from Ipswich has written to the county’s mental health trust with the hope of preventing future deaths.

Ellen Woolnough was 27 when she died on July 28, 2022, after struggling with her mental health for many years.

At the time of her death, Miss Woolnough, who was known to her family and friends as Ellie, was under the care of the Norfolk and Suffolk NHST Foundation Trust (NSFT) and was due to receive a visit from the Trust’s Crisis Resolution and Home Treatment Team just hours before she took action to end her life.

Miss Woolnough had also been referred NSFT’s Integrated Delivery Team (IDT) on May 20, two months previously.

However, this visit was cut short, with Miss Woolnough becoming distressed and leaving the meeting abruptly. A follow-up appointment was not arranged, and she was discharged from the team’s care days later.

Coroner Darren Stewart OBE was the coroner presiding over Miss Woolnough’s inquest, which came to an end in February.

Now, Mr Stewart has completed a Prevention of Future Deaths report, which he has sent to NSFT’s chief executive.  

Mr Stewart said he remained concerned about the IDT’s decision-making regarding discharging patients after failed appointments, and the Crisis team’s response to urgent referrals, in particular, risk assessment, safety planning and decision-making concerning downgrading referrals.

Miss Woolnough’s referral was downgraded the evening before she took action to end her life, with a call handler arranging for a home visit to take place the following morning, rather than that night.

Mr Stewart said he had received evidence that NSFT was making improvements, but that these had not assuaged his concerns as these had not yet been carried out.

In particular, he noted that the effectiveness of risk management training had been called into question by a number of witnesses he heard from. He also noted that key parts of the process of downgrading calls, such as the handover document between shifts, was still to be introduced. However, he did acknowledge that this process has been “tightened up”.

NSFT is dutybound to respond to Mr Stewart’s report by May 23.

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.