Family welcomes coroner's demand for change at mental health trust after teenager's death
PUBLISHED: 19:00 18 March 2019 | UPDATED: 07:44 19 March 2019
The family of a teenage girl who died while battling anorexia have welcomed a coroner’s demand for change at the region’s mental health trust.
Jacqueline Lake, senior coroner for Norfolk, will issue a regulation 28 report to the Norfolk and Suffolk NHS Foundation Trust (NSFT), calling on the authority to make improvements to note-taking and communication with outside agencies.
Ellie Long, a Wymondham High School student, suffered anorexia and depression and died on December 12, 2017.
After an inquest into her death earlier this year, her family hit out at failings by the mental heath trust, which has said it launched a “detailed review” after the Wymondham teenager’s death.
At the regulation 28 hearing at Norfolk Coroner’s Court, in Norwich, on Monday, Ms Lake told Ellie’s family, representatives for NSFT and the East of England Ambulance Trust that she would be issuing a report for two matters against NSFT.
Ellie’s mother Nicki Long, speaking to the BBC, said she would welcome the changes, particularly in relation to communication.
“It just seemed that there was no organisation,” she said. “Sometimes you would be expecting to see one member of staff and they weren’t there, you were never sure who would be included.
“You are relying on them to help you. You get a diagnosis, you think you will have treatment for that and you think you will get to a point where you will be alright.”
She said everything seemed “inadequate” and that changes around communication “really can make a difference”.
At the hearing, Ms Lake said she was satisfied NSFT had addressed previous concerns around its handling of written crisis plans and named lead care providers for patients.
On the auditing of routine records, she said: “Good record keeping is an integral part of a good service and must be second nature to all staff and is a key component in reducing risk.”
She added that, despite some improvements by the trust, she remained concerned about staff note-taking.
Ms Lake also called for the trust to improve its communication with outside agencies after communication with Ellie’s GP and school were highlighted as poor during the inquest.
Diane Hull, chief nurse at NSFT, said the trust had undertaken a “detailed review” after Ellie’s death.
“We value the input of the coroner’s service and families to help us drive improvements to services for the future,” she said.
She expressed condolences to the family, and said: “We accept the coroner’s report and are pleased that she has acknowledged the improvements made in relation to written crisis plans and the allocation of a named lead care professional.
“We also accept that a Prevention of Future Deaths report was still necessary to address the issues of auditing routine records and external agency communication.”
She said the trust will provide evidence to assure the coroner that the auditing of routine records would remain a priority for teams, and said action had already been taken to “strengthen communication with external agencies”.
“Staffing levels in our Eating Disorders Service were severely depleted in December 2017 but now all of its posts are filled,” she said. “We will continue to work with our commissioners to ensure that we provide a high-quality service to those who we serve.”
Ms Lake said she was satisfied with improvements at the ambulance trust, particularly in relation to its call handlers’ mental health training, but requested that it provided an update on its training this year.