Changes have been made to practices at a mental health trust after a woman with a history of mental illness killed herself on a visit to her sister in Dereham, an inquest heard.

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Jennifer McLeod, 53, hoped that spending time with family in Norfolk would help her to deal with a return of the depression she had suffered from for more than 30 years.

But an inquest yesterday heard that the team which had been treating Ms McLeod at her Bristol home, from the Avon and Wiltshire Mental Health Trust, did not contact Ms McLeod’s sister to alert her to the severity of her illness and that she had been having regular suicidal thoughts.

An internal review has led to changes since Ms McLeod’s death on July 27 last year, with the trust’s policy now to make contact with families and local mental health teams whenever patients move away for any period of time.

Ms McLeod’s sister, Sharon Davis, welcomed the news of the changes, though Norfolk coroner William Armstrong, who recorded a verdict of suicide as a result of a severe mental illness, said it was unlikely to have prevented Ms McLeod’s death.

The former nurse and care worker, of Nottingham Road, Bristol, was found dead in bushes on Rolling Pin Lane after inhaling a substance.

She had spent two days in hospital after taking an overdose on July 5, and had follow-up assesments.

Consultant psychiatrist Sarah Oke said Ms McLeod was prone to “recurrent” periods of depression, adding: “She had an understanding that she would get better but was feeling exhausted and overwhelmed at the thought of fighting another episode of depression.”

She said Ms McLeod, described as a “very bright and intelligent woman”, had admitted having suicidal thoughts.

Ms McLeod hoped visiting Norfolk would restore her confidence to overcome her depression, as it had in the past, and mental health staff gave her a 24-hour helpline contact number.

“We perhaps didn’t realise quite how seriously ill Jennifer was,” said Dr Oke. “If we had spoken to [Ms McLeod’s sister] I would not have said ‘don’t let her out of your sight’. I didn’t rate her risk as very high.”

Mrs Davis described her sister as “beautiful through-and-through”, and said she was pleased trust practices had changed.

“That’s all we can do for Jen: to check that somebody else will not fall through the net. That’s the best outcome we can have.”

She said her sister was a “kind, sweet girl”, with many friends, adding: “She wasn’t always depressed. She was a lovely girl and I want everybody to know that.”

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