Mental health staffing risks more deaths - coroner

Staff shortages at a mental health service could lead to more fatalities following the death of a trainee paramedic, a coroner said.

Rebecca McLellan, 24, from Ipswich, took her own life in 2023 while under the care of Norfolk and Suffolk NHS Foundation Trust (NSFT).

In a prevention of future deaths report (PFDR), coroner Daniel Sharpstone said in the months before McLellan's death, her care co-ordinator went on planned, prolonged leave and NSFT did not have a process to "adequately" manage the absence and there were a number of vacancies in the team.

NSFT said processes were already in place to cover planned leave and that further improvements had been made since McLellan's death.

An inquest, held in March at Suffolk Coroner's Court, heard that McLellan took her own life after struggling following a bipolar disorder diagnosis.

In the PFDR, Sharpstone pointed to McLellan having "been without a dedicated, named care co-ordinator for approximately nine weeks".

He said this was in part due to staff shortages, with four vacancies out of the youth team of 16.

Sharpstone said there was no system in place that "adequately highlights and manages planned, prolonged key care co-ordinator absence in the youth team, nor a formal, documented process that clearly and accurately ensures that the roles and responsibilities of named key care co-ordinators are adequately covered".

McLellan's mother, Natalie, had accused NSFT of routinely leaving her daughter without care.

But the coroner concluded that the level of care provided by the trust did not contribute to her death "more than minimally or trivially."

In a response to the coroner, NSFT described its process to manage prolonged, planned leave of a care-coordinator in the youth team, which included no new patients being allocated to them and the care co-ordinator preparing a handover that outlined a patient's intervention level.

The trust added that whether a patient is reallocated to another care-coordinator is based on their clinical need.

Patients were told about upcoming absences and how their care would be handled, the trust said.

Anthony Deery, the chief nurse at NSFT, said: "We have carefully considered the concerns raised by the coroner and have responded in detail, setting out both the processes already in place and the further improvements we have made since Rebecca's death.

"These include strengthening our arrangements for managing planned and unplanned staff absences, introducing clearer guidance to ensure continuity of care, and improving oversight of caseload management across our community teams.

"Alongside the wider improvements made following our investigation, we remain committed to learning from this tragic case and taking all necessary steps to deliver safer, kinder and better care for the people who use our services."

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