Suffolk 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), external, 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.”