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Coroner warns mental health staff shortages risk more deaths

A coroner has stated that staff shortages at a mental health service could lead to further fatalities, following the death of a 24-year-old woman in 2023.

  • Coroner Daniel Sharpstone issued a prevention of future deaths report after Rebecca McLellan's death.
  • The report highlighted that Norfolk and Suffolk NHS Foundation Trust (NSFT) lacked adequate processes for managing prolonged care co-ordinator leave and had staff vacancies.
  • NSFT stated it has since made further improvements to its processes for managing staff absences and ensuring continuity of care.

A coroner has warned that staff shortages within a mental health service could result in more deaths. This follows the 2023 death of Rebecca McLellan, a 24-year-old trainee paramedic from Ipswich, who was under the care of Norfolk and Suffolk NHS Foundation Trust (NSFT).

In a prevention of future deaths report, coroner Daniel Sharpstone noted that in the months before Ms McLellan's death, her care co-ordinator took planned, prolonged leave. NSFT reportedly did not have a process to "adequately" manage this absence, and the youth team had four vacancies out of 16 positions.

Ms McLellan was without a dedicated care co-ordinator for approximately nine weeks. However, the coroner concluded that the level of care provided by the trust did not contribute to her death "more than minimally or trivially."

NSFT stated that processes were already in place to cover planned leave and that further improvements have been made since Ms McLellan's death. Anthony Deery, chief nurse at NSFT, said the trust has strengthened arrangements for managing staff absences and introduced clearer guidance for continuity of care.

Why this matters: The coroner's report highlights concerns about the management of staff absences and continuity of care within mental health services, suggesting potential risks to patient safety.

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