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Coroner requests action by NHS trust to improve record keeping and communication following death of Ellie Long

The coroner investigating the death of 15-year-old Ellie Long has demanded action from Norfolk and Suffolk NHS Foundation Trust to prevent future deaths.

Posted on 19 March 2019

Fifteen-year-old Ellie Long from Wymondham in Norfolk died on 12 December 2017. Ellie’s inquest concluded with a narrative verdict on 16 January 2019 with the coroner stating that “Ellie Long took action which took her own life. The evidence does not show whether she intended to die”.
Ellie was referred by her GP to the Eating Disorder Service run by Norfolk and Suffolk NHS Foundation Trust in September 2017 as she had lost a significant amount of weight and had complained of low mood and trouble sleeping.
Ellie’s mother, Nicki Long, told the inquest that the support Ellie received from the service was inconsistent and disorganised. Nicki said that there was no regular format to the EDS meetings and they would turn up not knowing who they were going to see or what would be discussed. Ellie had told her that she found the meetings patronising and would get frustrated by the meetings.
The inquest heard evidence that during the three-month period that Ellie was under the care of the Trust’s Eating Disorder Service, the service was significantly overstretched with numerous job vacancies unable to be filled and was high on the Trust’s risk register. The inquest heard that there were shortcomings particularly in relation to crisis planning, risk assessing and in documenting Ellie’s care.
The inquest heard that the failure of the EDS to provide Ellie’s family with a crisis plan resulted in them calling the ambulance service and police on the evening of 9th December when they had become increasingly concerned about Ellie. Neither attended the home. Ellie was found by her mother at home the following morning.
At a hearing on Monday 18 March HM Senior Coroner Jacqueline Lake at Norfolk Coroner’s Court stated that she will be making Regulation 28 reports. The Coroner set out that she would be asking Norfolk and Suffolk NHS Foundation Trust (NSFT) to take action to ensure that full record keeping and disclosure requirements are fully adhered to at all times, including personal handwritten notes of meetings, and that this remains a priority. The coroner asked the Trust to take action to improve external agency communication and information sharing including with GPs and schools. The coroner also requested that she and Ellie’s mother be kept up to date with the outcome of the review by the East of England Ambulance Service NHS Trust of its training regarding mental health awareness.
The coroner set out at the hearing that she believed action to have already been taken by NSFT in relation to ensuring crisis plans are put in place for every patient and ensuring each patient has a named lead care professional.
Ellie’s mother, Nicki Long, said after the hearing: “I am pleased the Coroner has found that action needs to be taken to improve the service that NSFT provides. I hope that changes are made so that other families receive a better service and that some good can come from our tragedy.”
Elisabeth Andresen, solicitor at Leigh Day who represented Ellie’s family, added: “We thank the Senior Coroner for her thorough investigation into Ellie’s death and for highlighting the deficiencies in NSFT staff record keeping, and communicating and sharing information with external agencies. We hope that NSFT will take swift and immediate action to address her concerns.”