Mother pays tribute to her ‘kind, gentle, and sincere’ daughter as coroner rules on teenager’s death

Ellie Long's family spoke at the end of a harrowing five-day inquest into the death of the 15-year-old from Wymondham - and hit out a litany of failings by mental health professionals.

In a statement read by family solicitor Elisabeth Andresen, they said: 'Ellie was a beautiful, intelligent and caring young lady with the most wonderful smile. She was kind, gentle and sincere and always put others needs and feelings before her own.

'She was and still is a cherished daughter, granddaughter and niece. To Hannah, not only was she a devoted sister but also a best friend. 'To explain our feelings of loss is to explain the unthinkable, there simply are no words.

'Ellie struggled with her mental health in the last few months of her life and we feel that she was not given the support and treatment she needed by the Eating Disorder Service (EDS).'

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The Wymondham High School student, who suffered with anorexia and depression, took her own life in December 2017 - and her family said they felt 'failed by everyone'.

There were just six people in the team meant to be looking after Ellie, 15, when the number of referrals they were getting should have meant there were at least 20 people.

The family added: 'It is imperative that healthcare providers listen to the concerns of their service users and their families to ensure they get the necessary support and treatment and that there is a clear plan of action in the event of an emergency.

'As we heard during the inquest there were a number of issues which impacted on the care Ellie received including a lack of available staff, failures in crisis planning and the need for better record keeping. Some of these were reiterated by the coroner today.

'We hope that all these issues will be carefully considered by the trust to help them provide better care in the future.'

Senior coroner for Norfolk Jacqueline Lake gave a narrative conclusion.

There were tears from family members, who packed Norwich Coroners' Court on every day of the inquest, when Ms Lake gave her conclusion.

She said: 'Ellie Long took action which ended her life. The evidence does not reveal whether she intended to die.'

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The medical cause of death was recorded as hypoxic brain injury, due to cardiac arrest, due to hanging, due to anorexia and depression.

Previously the inquest heard how coping with Ellie's anorexia had become so difficult for the family that Mrs Long had been putting full-fat milk into semi-skimmed milk containers, and flattening thick cut bread with a rolling pin, in a desperate bid to get more calories into her daughter's body.

But she found the EDS, run by the failing Norfolk and Suffolk Foundation Trust (NSFT), 'disorganised'. She said: 'I know Ellie found them patronising and did not feel like they understood her. Every time I left the clinic I would be thinking what a waste of time it was.'

Ellie, who wanted to be a doctor and went to Wymondham High School, had told EDS psychotherapist Tania Pombeiro she had considered suicide in the past, and had written a note. And in their last meeting Ellie told Miss Pombeiro she 'wanted to end it all'.

But electronic notes were often not taken, and even if they had been Dr Kiran Chitale, child and adolescent psychiatrist, admitted she had not seen information relating to Ellie's past before deciding on treatment.

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She said had she known about Ellie's previous bouts of depression, and a suicide note written by the teenager, she 'would have insisted we kept more of an eye on her'. But she said the decision to prescribe anti-depressant fluoxetine would have been the same, as it was the only antidepressant licensed for children.

The inquest also heard how communication between the EDS and Ellie's GP, Dr Sarah Smith, had not been ideal and that the EDS was 'significantly understaffed'.

Neil Robertson, who was part of trust's serious incidents requiring investigation (SIRI) team following Ellie's death, said there were between six to eight members of staff working in EDS at the time - more than half the guideline of 20 based on the number of referrals they received.

He said the EDS team only had funding to employ 15 members of staff and that recruitment in that area was difficult.

The day before Ellie was found hanged emergency services refused to respond when her family called for help.

On December 9, 2017, Ellie was distraught and crying in her room.

Mrs Long said: 'She said 'I feel that I want to take my own life'.'

But when she called for an ambulance 'they told me there we no ambulances available and they would not come out and they recommended taking her to a walk in centre or the GP'.

It later emerged the call had been categorised incorrectly by a call handler, who recorded Ellie was thinking about suicide not threatening it, which did not prompt such an urgent response.

And when Ellie's sister Hannah called the police, the family was given an out-of-hours number for social services.

The EDS was closed outside of office hours, and the family felt there was no crisis plan in place.

Mrs Long said: 'If I had had a crisis plan I would have followed it.'

The next day Ellie was found hanged in her bedroom, but it took half an hour for an ambulance to arrive due to confusion over the house number.

She died two day later in hospital on December 12.

Ms Lake she would consider whether to write a report to prevent future deaths at a later date.

Speaking after the inquest NSFT medical director Bohdan Solomka said: 'Norfolk and Suffolk Foundation Trust would like to express its most sincere condolences to the family of Ellie Long.

'Ellie attended appointments in the trust's Eating Disorder Services (EDS) in the latter part of 2017, receiving input and assistance from a multi-disciplinary team including psychiatrists, a mental health nurse, dietician and family therapist. Ellie's mum was instrumentally important in providing Ellie with support at home as part of a family led approach to tackling Ellie's eating disorder linked with depression.

'The trust acknowledges all of Ellie's mum's efforts to do the best for her daughter and cannot imagine how difficult Ellie's passing and the subsequent coroner's inquest have been for Ellie's family.

'Our staff were shocked to learn that Ellie had taken action which ended her own life. The coroner's own independent psychiatric expert, Dr Pocari, gave evidence that Ellie reported no plan or previous attempts which would have alerted professionals.

The trust has undertaken a detailed review to learn as much as possible from Ellie's passing and to implement positive improvements in its services including audits on record keeping. Staffing levels in the team are now at full strength.'

Tom Quinn, director of external affairs at Norwich-based national eating disorder charity Beat: 'Inadequate coordination between eating disorder services puts vulnerable patients' lives at risk and it is essential that standards such as patient care plans and risk assessments are in place to prevent tragedies.

'In 2017 the Parliamentary and Health Service Ombudsman reached the same conclusion and the National Institute for Health and Care Excellence, NICE, has since published recommendations to improve care for people with these dreadful illnesses. These must be implemented.

'The Ombudsman's report also highlighted the need for better training on eating disorders for healthcare professionals to ensure that doctors and nurses are able to spot when someone is at risk. Currently, medical students receive less than two hours of eating disorder training through the whole of their four to six years of undergraduate study. Improved training would enable doctors to spot the signs and ensure someone receives adequate treatment, fast.'

'The government has allocated £30m each year in children and young people's services but it seems that not all of this money is being spent as intended. The government and NHS must ensure that all frontline services receive the funds to be sufficiently staffed and provide care to everyone who needs it.'