A Suffolk coroner has issued a formal warning to the Norfolk and Suffolk NHS Foundation Trust (NSFT) about staffing and systems failures in its youth mental health services after the death of a 24‑year‑old trainee paramedic.
Coroner highlights gaps in care‑coordinator cover
Dr Daniel Sharpstone, who concluded an inquest into the death of Rebecca McLellan (known as Becca) in March, found Ms McLellan had been left without a named care co‑ordinator for roughly nine weeks during 2023. The coroner said that period of unallocated care was partly a result of staff shortages: at the time there were four vacancies in a team of 16.
Ms McLellan, who lived with bipolar disorder, died on 20 November 2023. The inquest heard that a week after her care co‑ordinator began a planned period of prolonged leave she presented to NSFT offices “in considerable distress” and was told staff would call the police if she did not leave. Ms McLellan filmed that encounter and the footage was shown at the inquest.
“There is no documented system that I consider adequately highlights and manages planned, prolonged key care co‑ordinator absence in the Youth team, nor a formal
In a Prevention of Future Deaths (PFD) report dated 18 July, Dr Sharpstone set out concerns about the absence of a formal system to identify and manage planned prolonged absences by key staff in the youth team. The report warns that similar gaps could put other patients at risk if not addressed.
Trust response and local processes
NSFT has responded to the coroner’s findings, stating that, before going on leave, care co‑ordinators prepare handover documents and discuss leave arrangements with line managers. The trust said patients’ needs are reviewed in team meetings, and clinical team managers decide which patients must be reallocated during leave and which can safely remain without reallocation. It added that individual patients are informed in advance by their care co‑ordinator about plans to manage the absence.
The coroner’s PFD indicates those processes, in practice, did not prevent a prolonged period during which Ms McLellan had no named care co‑ordinator. The report recommends the trust reviews its approach to managing planned absences to ensure there is a documented, robust system that reliably protects vulnerable patients.
Wider implications for mental health services
The case underscores pressures facing NHS mental health teams, where vacancies and workforce instability can disrupt continuity of care. Continuity is widely regarded as important in the management of severe mental illness, including bipolar disorder, where timely contact and stable therapeutic relationships can be critical in detecting deterioration and arranging interventions.
Key facts from the inquest and PFD:
- Patient: Rebecca McLellan, aged 24, living with bipolar disorder.
- Date of death: 20 November 2023.
- Unallocated care‑coordinator period: approximately nine weeks in mid‑2023.
- Team vacancies at the time: four vacancies in a 16‑member team.
- PFD issued: 18 July 2026.
The coroner’s concerns will be considered by NHS oversight bodies and by NSFT, which is required to respond to the report with details of actions it will take. PFD reports are designed to prompt systemic change where an inquest identifies risks that might lead to further deaths.
What this means for patients and services
For patients, the absence of a named care co‑ordinator can mean delays in assessment, reduced oversight of risk and missed opportunities to escalate care. For services, the finding highlights the need for resilient workforce planning and clear contingency arrangements when key staff are on prolonged planned leave.
The coroner did not attribute blame to individual clinicians in the evidence published during the inquest; instead, the PFD seeks to ensure organisational learning. NSFT must now set out how it will strengthen handover procedures, ensure reallocation where needed and improve documentation so that planned absences do not leave vulnerable young people without appropriate support.
This case adds to a body of coroner findings across the UK that have spotlighted the consequences of staffing shortfalls and gaps in care coordination within mental health services. The practical steps the trust proposes in its response, and any subsequent action by regulators, will be key to determining whether similar risks are reduced in future.
