Rebecca Jessie Mclellan (known as Becca) · Prevention of Future Deaths report

On the 23rd March 2026 I resumed the Inquest into the death of Rebecca Jessie Mclellan (known as Becca)

The conclusion of the Inquest on the 25th March 2026 was Suicide

The Medical cause of death was given as:

1a) Hanging

On 20th November 2023 Police forced entry into Becca’s flat after concerns were raised by a colleague

Becca was found hanging ████████

Becca had left a final note and letters

The Postmortem concluded that her death was due to hanging

Becca was diagnosed with bipolar disorder in July 2022. She had been started on Aripiprazole but this was not tolerated

Becca had an initial mental health assessment on the 26th October 2022 when she described pressure of speech and agitation with intermittent suicidal thoughts but no plans or intent

She saw a Consultant Psychiatrist on the 22nd November 2022 and was started on Lamotrigine: she was in a mildly manic state

A referral to the ADHD team was made in March 2023. Becca did not see the ADHD team before her death

Becca had an urgent mental health review on the 23rd March 2023 as she was feeling flat

At review on the 5th April 2023 Becca was flat in mood with a number of life stressors

At her mental health assessment on 25th May 2023, Becca had made a concrete plan with a ligature and a piece of rope

A further review took place on 30th May, noting Becca’s mood had stabilised. Becca was functioning well and felt Lamotrigine ████████ mg a day was helping her

On the 7th August 2023 she presented in significant distress to the Trust. She had been without a dedicated care coordinator for approximately 9 weeks

There was an urgent assessment with a Senior mental health care practitioner who then reviewed Becca formally on the 10th August 2023

There was a further mental health review on the 16th August 2023, with Becca complaining of low mood, life stressors and being unhappy about lack of follow-up due to the absence of her care co-ordinator

Becca wasn’t keen on increasing the dose of Lamotrigine due to side effects: fluoxetine was started with monitoring for hyponatremia

On 14th September 2023 Becca said that the fluoxetine had improved her mood

There was a plan to refer her to the eating disorders team in October 2023. Her BMI was 16.4 at that time. She didn’t see the eating disorders team prior to her death

In late October 2023, Becca developed Stevens-Johnson syndrome secondary to her Lamotrigine. The Lamotrigine was slowly reduced. She remained on Fluoxetine

At her mental health assessment on 13th November 2023 Becca sounded flat in affect. She was anxious about starting Lithium as her Lamotrigine was being tailed off.

On the 31st May 2023, Becca’s care co-ordinator in the Youth team went on planned, prolonged leave.

On the 7th August 2023 Becca presented in significant distress to the Trust office that governed her mental health care. Due to issues with allocation, she had been without a dedicated, named care co-ordinator for approximately nine weeks. This was in part due to staff shortages. At that time, there were four vacancies out of the Youth team of sixteen. These were two Band 5, one Band 6 and a psychologist

As a consequence of her distressed presentation at the Trust office, a senior mental health care practitioner urgently took over the role as Becca's care co-ordinator

An update from the NSFT dated 2nd April 2026 described the current position with regards to vacancies as one Band 6 and one Assistant Psychologist in the Youth team.

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, documented process that clearly and accurately ensures that the roles and responsibilities of named key care co-ordinators are adequately covered during periods of planned leave. There is no process to ensure a dedicated, named care co-ordinator is identified to the mental health patient to provide continuity of care during prolonged periods of planned leave.

I consider that the risk of a lack of a dedicated and identified care co-ordinator for a significant period during planned leave creates an ongoing risk of future deaths for people with significant mental health disorders, so consider this a matter for a PFD report.