A coroner has asked mental health chiefs to ensure patients gain access to treatment they clearly need following the death of a 22-year-old Ipswich woman.
Kerry Hunter, who made seven attempts on her life in two years, was known to the Norfolk and Suffolk NHS Foundation Trust (NSFT) but was allowed home after she felt unable to access the therapy she wanted.
Dialetical Behavioural Therapy (DBT) was available by self-referral in Suffolk - but Miss Hunter's borderline personality disorder (BPD) made her unlikely to engage with services.
Coroner Nigel Parsley, who recorded a conclusion of suicide at a two-day inquest in Ipswich, has sent a Prevention of Future Deaths report to the NSFT highlighting matters of concern and asking for action to be taken - and giving the trust until June 20 to reply.
The inquest heard that NSFT had reviewed its treatment provision for individuals suffering from BPD and was planning to move the BPD Service treatment in-house rather than using external providers and will provide (DBT).
However, Mr Parsley said one of the facets of those suffering from BPD was not addressed by the NSFT plans.
He said: "Under the proposed new system, in order to access the NSFT BPD service, those suffering from the condition would have to agree to be transferred for treatment under the NSFT Integrated Delivery Team for onward referral to the new bespoke service."
The majority of individuals with a diagnosis with BPD will have had significant previous contact with their mental health service providers - Miss Hunter had had significant history of previous treatments over a number of years, none of which had proved effective.
None of the treatments would have been likely to have had a positive therapeutic effect, which in itself would compound the nature of BPD as a cycle of being offered ineffective treatment would enhance the loss of hope and optimism which is a feature of BPD.
Mr Parsley said: "Another facet of BPD was often an avoidant personality making sufferers unwilling or unable to engage with new individuals or teams.
"This being the case, I am concerned that the proposed requirement in the Norfolk and Suffolk Foundation Trust plan (which will require a BPD suffer to agree to a transfer to an Integrated Delivery Team before being placed onto the new service) may prevent some patients gaining the access to the treatment they clearly need."
Miss Hunter was found by her father, Adam Hunter, at her home in Vernon Street, Ipswich, on April 9, 2016, having taken an overdose of prescribed insulin medication.
A note close to the body confirmed her intention to end her life. She died on May 1, 2016.
The inquest heard that despite Miss Hunter's suicide attempts, one as recently as nine days before she was found, the NSFT deemed her mentally capable of refusing support.
No-one was available from the NSFT to comment yesterday but a statement is expected today.
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