A coroner has issued a warning over the death of a young woman who saw more than 25 members of the region's mental health crisis team in the 14 months before she took her own life.
Tamsin Grundy, 23, and from Denver, near Downham Market, was found dead at her home.
At an inquest into her death in March, Norfolk coroner Jacqueline Lake gave the conclusion of suicide, but said she was concerned at the number of people involved in her care and would be writing a report to Norfolk and Suffolk Foundation Trust (NSFT).
In the report, which was released on Tuesday and is designed to prevent future deaths, Ms Lake said: "Miss Grundy had a history of depression and had previously made attempts to end her own life."
MORE: Mother says the system is broken after 23-year-old daughter's inquestShe said: "Miss Grundy repeatedly spoke about her concern about the number of people involved in her care, particularly from the Crisis Resolution Home Treatment Team.
"It is understood Miss Grundy saw 25 plus members of the team in some 14 months.
"The evidence was that she found it difficult to relate to so many people, having to repeat the difficulties she was experiencing which she felt was adversely impacting on her mental health.
"It was not clear from the evidence that this issue was addressed during Miss Grundy's contact with the service."
Ms Lake also said this had been raised by Miss Grundy's family in the serious incident report produced by the trust after her death, but there was "no definitive, timed action arising from it, and no named person responsible for any such action".
NSFT has 56 days to respond to Ms Lake with a plan of action.
Following the inquest in March, Miss Grundy's mother, Rev Judith Grundy, said: "The system is really broken, there are too many people involved. I will miss her all my life."
Stuart Richardson, chief operating officer at NSFT, said at the time: "I am so sorry to hear about the tragic death of Miss Grundy and would like to offer my sincere condolences to her family and friends.
"We accept the findings made by the coroner today and will work with our commissioning partners to make every effort to reduce the number of different care professionals a service user sees when under the care of the crisis resolution and home treatment team.
"We are getting in touch with the family again and I hope to be able to meet with them soon to discuss this further."
If you are struggling with feelings of desperation or isolation you can contact the Samaritans on 116123.
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