Ellie Woolnough had the word “hope” tattooed on her arm. “It was all about hope,” Lisa, her mother, recalled at the end of an inquest into the suicide of her 27-year-old daughter. Ellie, from Ipswich, had suffered from anxiety since she was a child and was later diagnosed with emotionally unstable personality disorder. When she tried to take her own life in May 2022, her parents were desperate to find her treatment. Ellie was referred to mental health services run by Norfolk and Suffolk NHS foundation trust (NSFT). It repeatedly failed to provide her with any hope, according to evidence at her inquest, which concluded last week. Suffolk area coroner Darren Stewart criticised the trust for missed opportunities, failed interactions and “ineffective risk management and poor to non-existent safety planning”. Those under the care of NSFT say it is a depressingly familiar verdict, and challenges the trust’s claim that services are getting better. The health regulator assesses the trust’s performance as “requires improvement” after four “inadequate” assessments. The Campaign to Save Mental Health Services in Norfolk and Suffolk says the trust continues to be in a crisis sparked by austerity driven cuts in 2013. Its calls for a public inquiry into the trust’s failures were amplified last year when a review found 8,440 “unexpected” deaths among its patients or those it recently cared for. Inquests into deaths of those under the trust’s care have occurred with grim regularity at coroners’ courts in Norwich and Ipswich. Coroners were so concerned by issues raised in some of these inquests that they issued 25 prevention of future death (PFD) reports from 2017 to 2022. Last year promises by NSFT to address problems helped persuade coroners to stop issuing PFDs, bolstering the trust’s insistence that its services are improving. But Stewart does not appear to be convinced. He said the failings in Ellie’s care were serious enough to issue another PFD. In July 2022 Ellie again attempted to take her own life at her home in Ipswich and died the following week in hospital. A day before, Ellie had been contacted by the trust’s crisis team, after her father James contacted her GP expressing alarm at her wellbeing. But the four-minute triage call with a mental health nurse resulted in Ellie’s case being downgraded from emergency to urgent. Under trust guidelines such downgrades are supposed to be agreed with another nurse, but only one was involved, the inquest heard. And within 80 seconds of the triage call, Ellie was told the crisis team could not send someone out to visit her due to staff shortages. She fatally self harmed the next day. “We know that had someone come out that night it might have been different,” Lisa said. The trust’s recording of the four-minute assessment call was deleted, as it asserted that procedures were properly followed. But Ellie had made a recording of the call on her phone. The assessor’s voice was barely audible, but the disclosure of the recording at the inquest forced the trust to change its version of what was said three times in written evidence and a fourth time under questioning. The coroner said the trust’s evidence had “more holes than Swiss cheese”. He said its failure to retain the recording of the call amounted to a “very serious” breach of its duty of candour. Similar issues have been raised before. In 2022 a different coroner found the trust had “falsified” observations about Eliot Harris before his death at the age of 48. In Ellie’s case the coroner found the trust displayed a “race to discharge” her despite her symptoms. Stewart said he was concerned by an “emphasis on limiting contact with patients, which is the opposite of what the public would be expected to have from publicly funded mental health services”. Stewart stopped short of concluding that trust’s failures contributed to Ellie’s death. But his verdict left her parents wondering what might have happened with better care. Lisa said: “If therapy had been put in there was always the hope. And the crisis team coming out that would have been a sign they believed in her and things were in place to make her well. That’s all she wanted, a normal life.” The trust’s reluctance to treat patients is also a source of acute concern for Norfolk GP Pallavi Devulapalli, who is the Green party spokesperson on health. She said: “Patients are either refused help from mental health services because they are deemed not well enough, or they if do get assessed there is no follow up. So they are back in the care of GPs which is very irresponsible. It leaves patients feeling abandoned and let down.” A teenager came to her surgery showing dangerous signs of psychosis, she recalled. The trust agreed to care for him only after Devulapalli’s insistent pleading. “If I hadn’t jumped up and down, I dread to think what might have happened. He was a risk to himself and his mother. I had to say: ‘what needs to happen before you take action?’” She said the trust has struggled to recruit psychiatrists, and added: “The trust seems to have a lack of understanding of just how devastating mental health problems can be, not just for the individual, but for everybody around them as well.” This year alone there have been four suspected murders by two people who had contact with the trust. From 2012 to 2018 there were 15 homicides by NSFT patients, according to figures obtained under freedom of information requests by the charity Hundred Families which campaigns for the victims of mental health homicides. Its founder, Julian Hendy, says: “The problem we see in places like Norfolk and Suffolk is that people are not followed up robustly enough, or there’s a sort of optimism bias that it will be okay, when the services are not well enough equipped to deal with people who are significantly at risk.” He is supporting the family of Vera Croghan, who was killed in 2020 by a fire in her Norwich house which was started by her grandson, Chanatorn Croghan, when he was under the care of NSFT. Its treatment of him will be considered at Vera’s inquest due in July. The family has urged the trust to be open and transparent. In a statement, their solicitor Leanne Devine, a partner at Leigh Day, said: “Vera’s family are concerned that the trust comply with duty of candour obligations and are worried about the recent reports of the trust providing misleading information.” An NSFT consultant psychiatrist who recently left the trust has warned that its approach is unsafe. “People who need treatment are put on managed waiting lists, which are not really managed at all, and that’s inherently dangerous. They might get a phone call to ask ‘are you okay?’ That is not managing or treating people. It is so stupid.” The source said the trust should not have been upgraded by the regulator as services have deteriorated. “It has only got worse over time. You wait for the grown ups to arrive but nothing is ever done,” they said. A former senior manager at the trust described it as “dysfunctional” and “one of the worst examples of the management paradigm that has been applied to mental health services in the NHS”. The manager said the trust should harness the anger and energy of local campaigners to help it improve and focus on care rather than reputation. The psychiatrist points out that assessments of patients used to be done by doctors or senior nurses. But over time the qualifications of those conducting assessments have decreased. “I know of assessment by band fours, which are essentially unqualified staff with no experience,” they said. They recalled the inadequate care given to Alan Hunter, 72, before his suicide in 2020. As he struggled with depression, NSFT staff suggested he try Sudoku puzzles to help with anxiety, while his family was told there were no psychiatrists suitable for people of his age. The former consultant said: “Essentially there was nobody in post and he didn’t get seen. It was a real mess.” Such blunt honesty about the trust failings has not been extended to Ellie’s parents, who represented themselves at the inquest. Her mother, Lisa, said: “We’ve lost hundreds of hours ploughing into this, which has been awful. And it could have been avoided if they had been open and transparent. It has put a kink in our grieving.” She added: “We’re not trying to bring down the trust, we just want improvement because Ellie’s care wasn’t good enough. I don’t want their apology. They need to take their sympathy and turn it into empathy and give it to these kids who are walking through their doors.” She added: “We won’t be the last family unfortunately.” An NSFT spokesperson said the trust is on a “a rapid and much needed journey of improvement” strengthened by the recent appointment of its chief executive, Caroline Donovan. “Caroline has a proven track record for transforming mental health service provision and has made improving health, improving care, improving value and improving culture clear organisational priorities,” they said. “We have listened carefully to the concerns that were raised during the inquest and are determined to learn and improve. “It is clear that there was more we could – and should – have done to support Ellen. We are already taking actions to improve, which include reviewing the processes in place to ensure safety when a patient leaves midway through an assessment. We have also introduced extra steps to make sure that relevant recordings of phone calls are retained to support the inquiries which take place at the inquest.”