Mental health trust changes systems after tragic death of Norwich law student Katrina Rolph

Katrina Rolph. Picture: The Rolph family

Katrina Rolph. Picture: The Rolph family - Credit: Archant

An 'academic high flyer with an indomitable spirit' died after being unable to access mental health services, an inquest heard.

Katrina Rolph, 20, from Norwich, had dropped out of studying law at Bangor University in early 2016 with a variety of physical symptoms, which she had put down to copper poisoning from a contraceptive coil.

Experiencing anxiety and depression since 2013, she began exhibiting more alarming symptoms towards the end of 2015, including hallucinations, thoughts of being persecuted and suicidal thoughts. She spoke of demons and warped reflections in the mirror surrounded by 'horrible things', Norfolk Coroner's Court heard.

Her GP, Dr Peter Lawson of Market Surgery in Aylsham, made an urgent 72-hour referral to the Norfolk and Suffolk NHS Foundation Trust on March 16. After triage, the youth services team disagreed and made a routine appointment for two months later.

The following week Katrina was visited at home by a private consultant psychiatrist who made another 72-hour urgent referral to NSFT, via Dr Lawson on March 30.

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That referral was never actioned. The inquest heard that due to 'human error' in the admin team it was never seen by the clinical triage team.

The appointment for May 27 was then cancelled with three days notice as the youth services team was restructuring and had an 'unusually high level of referrals'.

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When Katrina missed the next appointment on July 24, the team discharged her on August 12, having never assessed her face to face.

During a family holiday to Hempstead in September Katrina went missing and was found hanged in nearby woodland on October 2 last year.

Katrina's mum Louise Hutchinson-Rolph said: 'We became more and more desperate to find a way to help her. Her behaviour suggested to me she had given up all hope.

'In the final months of her life she put on a brave face. It was obvious she wasn't the person she once was and had accepted she was going to end her life. She had simply had enough of suffering.'

Area coroner Yvonne Blake ruled out suicide, saying: 'Katrina took her own life while the balance of her mind was disturbed and therefore her intent was unclear,' she said in a narrative verdict.

The mental health trust has made 'genuine attempts' to change their systems as a direct result of her death, the inquest heard.

Claire Pratt, clinical team leader in youth services, said when Katrina's appointment had been cancelled 'the service was having to deal with an unusually high level of referrals and was in the process of restructuring.

'There were changes going on while this was happening,' she said. 'I inherited a team that was struggling to function to time scales. We have changed the way we offer routine assessments by making them more flexible.

'Changes as a direct result of this case are that if a young person does not respond, rather than being automatically discharged they are reviewed by the triage.'

A pilot scheme is also underway in Great Yarmouth to ensure more detail is passed on from GPs in referrals.

The EDP has been running its Mental Health Watch campaign since October 2015. Its aims are to reduce the stigma around mental health issues, raise awareness as well as campaign for improved services in Norfolk and Suffolk.

The Samaritans are available to talk 24 hours a day by calling 116 123.

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