Ellie Woolnough had the word ‘hope’ tattooed on her arm. “It was all about hope,” Lisa, her mother, recalled at the end of an inquest into her 27-year-old daughter’s suicide.
Ellie, from Ipswich, had suffered from anxiety since childhood and was later diagnosed with emotionally unstable personality disorder. When she attempted suicide in May 2022, her parents were desperate to find treatment for her.
Ellie was referred to Norfolk and Suffolk NHS Foundation Trust (NSFT) mental health services. It has repeatedly failed to give her any hope, according to evidence from her inquest, which concluded last week. Suffolk coroner Darren Stewart criticized the trust for missed opportunities, failed interactions and “ineffective risk management and poor to non-existent safety planning”.
Those in NSFT’s care say it is a depressingly familiar verdict, and dispute the trust’s claim that services are getting better. The health regulator rates the trust’s performance as “requires improvement” after four “inadequate” ratings.
The Campaign to save mental health services in Norfolk and Suffolk says the trust remains in crisis sparked by 2013 budget cuts. Calls for a public inquiry into the trust’s failures were intensified last year when a study found 8,440 ‘unexpected’ deaths were among the patients or among those managed by the fund. recently taken care of.
Inquests into the deaths of those in the trust’s care have taken place with grim regularity at coroner’s courts in Norwich and Ipswich. Coroners were so concerned about the issues raised in some of these investigations that they issued 25 Prevention of Future Deaths (PFD) reports from 2017 to 2022.
NSFT’s promises last year to tackle the problems helped convince coroners to stop issuing PFDs, reinforcing the trust’s insistence that its services were improving. But Stewart doesn’t seem convinced. He said the deficiencies in Ellie’s care were serious enough to issue another PFD.
In July 2022, Ellie attempted suicide again at her Ipswich home and died in hospital the following week. A day earlier, Ellie had been contacted by the trust’s crisis team after her father James contacted her GP and expressed alarm about her welfare. But the four-minute triage call with a mental health nurse resulted in Ellie’s case being downgraded from emergency to urgent. Under trust guidelines, such reductions should be agreed with another nurse, but only one was involved, the inquest heard.
And within 80 seconds of the triage call, Ellie was told that the crisis team could not send anyone to visit her due to staff shortages. The next day she fatally injured herself.
“We know that if someone had come out that night, things might have been different,†Lisa said.
The trust’s recording of the four-minute assessment meeting was deleted as it claimed procedures had been followed correctly. But Ellie had recorded the conversation on her phone. The assessor’s voice was barely audible, but the disclosure of the recording at the inquest forced the trust to change the version of what was said three times in written evidence and a fourth time during questioning.
The coroner said the trust’s evidence had “more holes than Swiss cheese”. He said the failure to retain the recording of the conversation amounted to a “very serious” breach of his duty of honesty.
Similar issues have been raised before. In 2022, another coroner found that the trust had “falsified” observations about Eliot Harris before his death at the age of 48.
In Ellie’s case, the coroner found the trust was in a ‘race to fire her’ despite her symptoms. Stewart said he was concerned about the “emphasis on limiting contact with patients, which is the opposite of what the public would expect from publicly funded mental health services.”
Stewart did not conclude that the trust’s failures contributed to Ellie’s death. But his verdict left her parents wondering what could have happened with better care. Lisa said: “If there was therapy involved, there was always hope. And the crisis team coming out would have been a sign that they believed in her and that things were ready to make her better. That’s all she wanted: a normal life.â€
The trust’s reluctance to treat patients is also a source of acute concern for Norfolk GP Pallavi Devulapalli, the Green Party’s health spokesperson. She said: “Patients are being refused mental health help because they are deemed not well enough, or if they are assessed there is no follow-up. So they are back under the care of general practitioners, which is very irresponsible. It makes patients feel abandoned and abandoned.â€
A teenager came to her practice showing dangerous signs of psychosis, she recalled. The trust agreed to take care of him only after Devulapalli’s persistent plea. “If I hadn’t been jumping up and down, I wouldn’t even think about what would have happened. He was a danger to himself and his mother. I had to say. ‘What needs to happen before you take action?â€
She said the trust has struggled to recruit psychiatrists, adding: “The trust appears to have a lack of understanding of how devastating mental health problems can be, not just for the individual, but for everyone around them. ”
This year alone, there have been four suspected murders committed by two people who had contact with the trust. From 2012 to 2018, there were 15 murders committed by NSFT patients, according to figures obtained through freedom of information requests by the mental health charity Hundred Families, which campaigns for the victims of murders.
Its founder, Julian Hendy, says: ‘The problem we see in places like Norfolk and Suffolk is that people aren’t being followed up strongly enough, or there’s a kind of optimism that things will be fine if the services aren’t. well enough equipped to deal with people at significant risk.â€
He is supporting the family of Vera Croghan, who died in 2020 in a fire at her Norwich home, which was started by her grandson, Chanatorn Croghan, while in the care of NSFT. His treatment will be considered at Vera’s inquest in July.
The family has urged the trust to be open and transparent. In a statement, their lawyer Leanne Devine, a partner at Leigh Day, said: “Vera’s family are concerned that the trust is complying with its duty of candor and are concerned about recent reports of the trust providing misleading information.” €
An NSFT psychiatrist who recently left the trust has warned that its approach is unsafe. “People who need treatment are put on managed waiting lists, which are not managed at all, and that is inherently dangerous. They might get a phone call asking, “Are you okay?” That’s not managing or treating people. It’s so stupid.â€
The source said the trust should not have been upgraded by the regulator as service delivery has deteriorated. ‘It’s only gotten worse over time. You wait for the adults to arrive, but nothing ever happens,” they said.
A former senior manager at the trust described it as ‘dysfunctional’ and ‘one of the worst examples of the management paradigm applied to mental health care in the NHS’. The manager said the trust must harness the anger and energy of local campaigners to help it improve and focus on care rather than reputation.
The psychiatrist points out that patient assessments used to be done by doctors or senior nurses. But over time, the qualifications of those conducting assessments have diminished. “I know of a review by band fours, which is essentially unqualified personnel with no experience,” they said.
They recalled the inadequate care given to 72-year-old Alan Hunter before his suicide in 2020. As he struggled with depression, NSFT staff suggested he try Sudoku puzzles to help with anxiety, while his family was told that there were no psychiatrists suitable for his people. age.
The former adviser said: ‘Essentially there was no one at his post and he was not seen. It was a real mess.â€
Such blunt honesty about the lack of trust was not expressed to Ellie’s parents, who represented themselves at the inquest. Her mother, Lisa, said: ‘We spent hundreds of hours on this, which was devastating. And it could have been prevented if they had been open and transparent. It has caused a kink in our mourning.â€
She added: ‘We’re not trying to break trust, we just want improvement because Ellie’s care wasn’t good enough. I don’t want their excuses. They need to turn their compassion into empathy and give it to these children who walk through their doors.”
She added: “We won’t be the last family, unfortunately.”
A spokesperson for NSFT said the trust is on a “rapid and much-needed journey of improvement”, reinforced by the recent appointment of CEO, Caroline Donovan.
“Caroline has a proven track record of transforming mental health care and has made improving health, improving care, improving value and improving culture clear organizational priorities,” they said.
“We have listened carefully to the concerns raised during the investigation and are committed to learning and improving.
“It is clear that we could – and should – have done more to support Ellen. We are already taking steps to improve, including reviewing existing processes to ensure safety when a patient leaves mid-assessment. We have also introduced additional steps to ensure that relevant recordings of telephone conversations are retained to support the investigations taking place during the inquest.”