Following the inquest into the death of 27-yr old Ellen ‘Ellie’ Woolnough

(Photo credit: from Ipswich Star, article – ‘NSFT criticised in inquest for Ipswich woman Ellen Woolnough’)

During the last week of January 2024 and the first week of February 2024, there is an inquest underway, for Miss Woolnough who was a service user who died whilst under the care of NSFT. Miss Woolnough had suffered with her mental health since the age of 6 and was diagnosed with anxiety and EUPD (emotionally unstable personality disorder). Her family remember her as a curious and fun person who “added a touch of sparkle wherever she went and made everyone who she spoke to feel special”. During the pandemic she cared for elderly people, and her kindness ‘grew as she did’. Miss Woolnough often found that physical illnesses would cause a downturn on her mental health, this was known and explained to the court by her Father.

Miss Woolnough’s parents had spend “hundreds of hours” going through documents and notes prepping for the inquest, as they were determined to do “one last thing for Ellie”. Yet, families should not need to be fighting for justice at a time they should be grieving. They explained that NSFT had been a “law unto themselves” in not providing evidence, or delaying more than 6 months in giving evidence after request.

She said “NSFT needs to start listening to the voice of the person who is using their service”

She asked the presiding coroner Mr Darren Stewart OBE to consider the missed opportunities identified during her daughter’s inquest, and said that her family would like to see NSFT develop a “less Machiavellian attitude to the inquest process”. (Fossett, 2024)

On Tuesday 30th Jan, the second day of the inquest, a mental health nurse from NSFT crisis team was speaking in court.

Miss Woolnough was called twice by the crisis team at 5:31pm on July 19th 2022, the day before she was found at home by family and taken to Ipswich hospital where she remained in intensive care for 8 days before dying on 28 July, 2022.

As Miss Woolnough was poorly with a sickness bug, which has caused her mental health to worsen in the past, the crisis team felt it suitable to wait and visit her at 11am the following day. The call was taken at 5:31pm and according to NSFT’s policy, ‘urgent’ calls should be assessed within four hours. Miss Gifford the mental health nurse, explained that due to staff sickness, a visit before midnight would be unlikely.

According to Miss Gifford, Miss Woolnough agreed and said she was able to keep herself safe. Yet her parents said Miss Woolnough wouldn’t have rejected a nighttime visit as time “would have been irrelevant” to her. It was explained by Miss Woolnough’s father that she had removed all of the clocks out of her flat as keeping track of time caused more anxiety.

Miss Woolnough’s own phone transcripts were able to clearly hear her side of the conversation but not Miss Gifford’s side of the conversation.

It should be the norm to routinely record calls at the crisis team, which was confirmed, however Miss Gifford wasn’t sure how long they were kept. Miss Gifford also explained that she was not aware of the incident which lead to Miss Woolnoughs death, following the phone call until some time later, maybe even several days.

It was confirmed on Friday 2nd in court, that NSFT’s recording of the call was destroyed by the trust. The recordings are usually held for a month, and this was not a call that was identified as one to keep. Mr Stewart, the presiding coroner, expressed concerns at the lack of keeping the evidence, considering the trust was made aware on the morning after the call, that Miss Woolnough was in hospital following a serious incident.

“I find it breathtaking that the Trust seems to think that isn’t a problem,” he said. “I find it difficult to understand how in those circumstances, that recording was not kept.” (2024)

The legal representitive for the trust argued that oral statements and Miss Gifford’s statements have been submitted, which have been doubted by the court, considering the credibility of such delayed statements being written by Miss Gifford who didn’t recall the phone calls.

He described the evidence as having “more holes than Swiss cheese”.

This is sadly not the first time NSFT has delayed evidence or been shown to have poor record keeping. Time and again, the trust has often delayed giving over information, whether that would be in front of a scrutiny committee, giving information to the CQC or to its own commissioned reviews. Sadly, this is another case of someone not only been failed in crisis, but then a family fighting hard, trying to get justice also facing the same attitude of delay, cover up and defence. This case also should not fall fully onto one nurse who made the call. There will have been management, handovers, coordination and supervision around many decisions within the crisis team, and cross-organisation communication between general hospital and NSFT. These decisions should also new scrutinised, and not just left to one staff member.

UPDATE 13th February –

The inquest for Miss Woolnough drew to an end this week.

The presiding coroner Mr Darren Stewart OBE read a statement from CJ Newcombe, the partner of Miss Woolnough. Within the statement, he described Miss Woolnough as ‘the most beautiful girl in the world‘, who offered help to anyone in need and stood up against bullies so selflessly. He also shared that Miss Woolnough was ‘the person he ought to have spent the rest of his life with’.

The inquest resulted in, Mr Stewart concluding that Miss Woolnough had taken her own life whilst suffering with her diagnosed mental health condition. He also explained that in the balance of probabilities, there was not a certain decision that the phone call with NSFT contributed to the death of Miss Woolnough. However, he did express concerns about her interactions with NSFT which he described in court as “inadequate” and that the interaction “missed opportunities”. He also repeated his frustrations that the recording of the phone call was not retained by the trust, especially when they were made aware in a timely manner of Miss Woolnough’s serious incident and subsequent death, which would have been well within the month in which they would then get rid of the unnecessary recordings.

“The failure to retain that call and allow it to be deleted is at best poor practice which does not meet the Trust’s duty of candour to this court, let alone its ability to form an effective and appropriately reflective response,” he said.

He did acknowledge some of the trusts improvements but also made comment that as yet these had not all been implemented.

This case will result in Mr Darren Stewart writing a Prevention of Future Death Report in regards to the trust’s conduct. This will be the first PFD report issued to the trust since 2022. These are recommendations to ensure that a death in similar circumstances does not happen again. It should put into focus contributing or possible contributing factors that are practical and possible to enact or change.

Miss Woolnough’s parents hope that there will be less stigma towards the diagnosis of EUPD and that wished it could be better understood.

They said there were not interested in receiving sympathy from NSFT, who they had previously described as “Machiavellian” and “a law unto themselves. I don’t want their sympathy – they should take their sympathy and turn it into empathy for the next kids who are coming through their doors,” said Mrs Woolnough.” (Ipswich Star, 2024)

Her parents now relieved to feel like they can ‘bring her home’ and no longer have the ‘kinks in the grieving’ that the preparation and the inquest itself brought with it.

The campaign member’s thoughts are with them.

On a side note and one to think about.

A lot of service users and carers also may struggle with the statement from the inquest “If you stopped the story here, with Miss Gifford offering her an appointment the next day, I think almost everyone would expect Miss Woolnough to have gone to that appointment the next morning.” Service users and carers have often struggled getting the appropriate help in time as they are often offered a ‘golden appointment’ to hold all of their hopes on. Within that appointment, which may or may not be cancelled, could be helpful or cause more confusion and hopelessness. Many professionals and even society can think that golden appointments can be somewhat of a protective factor but sadly that is not always the case. Some people may find the contact itself helpful but if it is a treatment plan they need, one appointment may not give the level of change or psychiatric/therapeutic input that is needed, therefore it can be dangerous to put a lot of emphasis and responsibility on one appointment being a panacea when one is in crisis.

Author of Ipswich star article: Abygail Fossett.

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