Ellie Jane LONG · Prevention of Future Deaths report

On 13/12/2017 I commenced an investigation into the death of Ellie Jane LONG, aged 15. The investigation concluded at the end of the inquest on 16/01/2019. The conclusion of the inquest was: Ellie Long took action to end her own life. The evidence does not reveal whether she intended to die.

The medical cause of death was:
1a Hypoxic Brain Injury
1b Cardiac Arrest
1c Hanging
II Anorexia, Depression

Ellie Long was receiving treatment in the community from the Eating Disorder Service. She was diagnosed with Anorexia Nervosa and Depression. On the morning of 10 December 2017, Miss Long went to her bedroom, where she was found hanging later that morning. Emergency Services were called, and Miss Long was taken to Norfolk and Norwich University Hospital where she died on 12 December 2017.

1. Record keeping and Auditing of Record keeping

a) Not all records were properly recorded on Lorenzo. Further, personal handwritten notes were made of some meetings which were not then reflected in the electronic records. Some of these notes only came to light during the inquest hearing. It is, of course, imperative that all staff recognise their obligations in respect of keeping full and contemporaneous electronic records and that full disclosure of all relevant documents is made in a timely fashion before the inquest commences. This avoids potential delay in the inquest process and further distress to the family.

b) Some action has been taken by NSFT in this respect, not least in that the team is now better resourced staff-wise. Further action has been and is being taken to ensure staff appreciate the importance of full record keeping. An audit of the records has been undertaken to ensure full compliance with record keeping requirements but this will only continue until 100% compliance has been achieved.

c) Concern remains in that staff do change over time and matters raised now do not necessarily remain at the forefront of an individual’s mind, especially when under time pressure. Good record keeping is an integral part of any good service and must be second nature to all staff. It must be fully appreciated by all as “a vital component in the management of risk”. Further, record keeping has been raised elsewhere as a matter of concern within NSFT.

d) I have concern that full record keeping and disclosure requirements will not remain a priority.

2. Communication with External Agencies

a) An initial full, updating letter was sent to Ellie’s GP. However no further updating information was sent. A letter was written providing updating information, but this was not sent. No further updating information was sent to the GP by telephone, letter or email.

b) The evidence heard is that efforts were made to contact the school by telephone. However, the school had no record of any such calls. There is no evidence of email or written correspondence or further telephone calls in an effort to communicate with the school.

c) It is accepted by the Trust that sharing of relevant information is necessary. NSFT has indicated it will “remind staff of the importance of recording efforts to share information/maintain communication”.

d) Sharing of information and communication with external agencies is a matter which has been raised with NSFT on previous occasions. The importance of “recording efforts to share information ...” may not be sufficient to prevent future deaths. It is the importance of sharing information and communicating with external agencies that should be addressed here. Recording of information is dealt with at Point 1 above.