Failures of mental health services 'significantly contributed' to the suicide of a mother struggling with depression and post-traumatic stress disorder, a jury has found.

Katherine Rought-Rought died at her home in North Park Avenue in Norwich on June 1, 2016 from asphyxiation due to strangulation.

Only hours earlier she had been discharged by the Crisis Resolution and Home Care Team (CRHT) from Norfolk and Suffolk NHS Foundation Trust.

Following a four day inquest, area coroner Yvonne Blake said she had 'not been able to find a rationale' for the decision of CRHT not to take on her care in April, and would be writing informally to NSFT to express her concerns.

'I think there were gaps in the care given to Ms Rought-Rought,' she said.

Mother-of-one Ms Rought-Rought, 36, had suffered with mental health problems since she was 18-years-old, had been an inpatient at Hellesdon Hospital, and was first in contact with mental health services since 2001.

The inquest heard Ms Rought-Rought had gone to the Norfolk and Norwich University Hospital's accident and emergency after a serious incident of self-harm in April 2016 and just over a month later made threats to take her own life.

Mrs Rought-Rought described her daughter as a 'great artist and musician' with a 'great sense of humour'.

In a written statement, she said: 'I strongly believe Katherine should have been sectioned.'

Ms Rought-Rought's past treatment included cognitive behavioural therapy and treatment in the run up to her death included electroconvulsive therapy (ECT) and antidepressant medication.

But after five hours of deliberation, a jury found 'no alternatives were actively pursued' and the ECT led to a 'deterioration in her mental health...culminating in her decision to commit suicide.'

They added she 'did not receive appropriate care' which was 'inadequate both in scope and implementation', which was 'likely to have had a bearing on her decision to commit suicide.'

The inquest had heard from Dr Robert Higgo, an expert clinical psychiatrist, who said the set up of mental health services across the country were 'terrible' because the separation of mental health care into different teams meant no one person had an overview of a patient.

He said: 'Mental health services have changed substantially since I have been in psychiatry. Back in the day all new referrals were seen by a medical doctor, a psychiatrist. Now people are more seen by a non-medic and more never see a medic.'

He added he felt Ms Rought-Rought should have been admitted to hospital - and would have been had she seen a psychiatrist.

Mrs Rought-Rought had been visited by the CHRT for three days before she was discharged, and staff nurses told Norfolk Coroner's Court: 'There was nothing that indicated an immediate risk.'

After deliberating for more than five hours, the jury returned a unanimous conclusion of suicide.

It was appended with a narrative conclusion, which read: 'Katherine did not receive appropriate care and this is likely to have had a bearing on her decision to take her own life. Her care plan was inadequate both in scope and implementation.

'Excessive and inappropriate change of her medication was undertaken in late 2015, with no changes in her drug regime after February 2016 despite severe incidents in April and May and the concern expressed in reports from consultant psychiatrists.

'After the incidents in April consultant psychiatrists strongly recommended either admission or involvement of the CHRT - these recommendations were not followed. Katherine received apt visits, but upon her refusal of continued visits, no review or further assessment was undertaken.

'There is no record of a formal care plan review in light of the April events and the consultant psychiatrists assessment.

'There was a failure to undertake an assessment under the Mental Health Act following the incident on May 29. On the balance of probability this significantly contributed to Katherine's death.

'A review of the evidence supports the view that Katherine did not have an effective advocate for her needs.'

Area coroner Yvonne Blake said she will write to NSFT with concerns including 'people being passed from team to team, falling through the cracks with not enough supervision.'

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'Lessons learned'

NSFT said they have carried out a detailed investigation in the wake of Ms Rought-Rought's death and 'will make further necessary changes'.

'Having heard and digested the evidence provided at the inquest, the jury recorded a narrative conclusion which the Trust notes expresses some concerns over the care provided to Ms Rought-Rought,' said a spokesman.

'Norfolk and Suffolk NHS Foundation Trust carried out a detailed investigation into Ms Rought-Rought's care prior to the inquest. The Trust strives hard to ensure that lessons are learned and improvements made in the clinical care provided to patients endeavouring to create an excellent standard of care for all.

'The Trust will consider the conclusions and lessons from the inquest and make any further necessary changes.

'The Trust wishes to send its sincere condolences to Ms Rought-Rought's family at this extremely difficult time.'