Promising law student Katrina Rolph had “lack of care” before her death despite warning signs

Katrina Rolph. Picture: The Rolph family (Image: Archant)

But the 20-year-old never had a mental health assessment despite two urgent referrals from her doctor, which a coroner described as 'troubling'.

The Norfolk and Suffolk NHS Foundation Trust (NSFT) have since vowed to change their systems, and the area coroner for Norfolk will write to Norfolk Police after they failed to inform mental health services of an apparent suicide attempt.

An aspiring judge, Katrina had been forced to drop out of Bangor University in early 2016 after various physical symptoms, alongside anxiety and depression.

Despite having suicidal thoughts, an urgent referral made on her behalf to NSFT in March was lost and an appointment in July was cancelled due to workload.

Dr Peter Lawson of Market Surgery in Aylsham made both urgent referrals within a fortnight.

'My expectation as she would be seen by the mental health team within 72 hours,' he said. 'My understanding is the youth service want to see young people at an early stage.'

Dr Lawson also said 'in hindsight' he should have included a referral letter from the consultant psychiatrist to NSFT with the second referral, which he did not.

'I did not hear anything further from NSFT,' he said. 'Most of Katrina's concerns following that were to do with her physical health.'

Peter Lakin, registered nurse with the patient safety team, conducted the serious incident investigation following Katrina's death.

'There were care and service delivery problems in areas of information sharing and youth team capacity, appointment and discharge process, and an issue of contact between service users father and our crisis team,' he said.

'Mr Rolph had contacted someone in the crisis team in March as she was expressing suicidal thoughts and was told they could not help him as he was not acting with her consent. Formal discussions have been had with members of staff in that team.

'The fact the second referral had not been acted upon was obviously of great concern for us.'

Also of concern was an incident in May when Katrina went missing and threatened to jump from a church tower. Police were called but details of the incident were not shared with mental health services.

Area coroner Yvonne Blake said after the inquest she would be writing informally to the force.

Katrina's mum, Louise Hutchinson-Rolph, said the family had felt 'unable to help her'.

'From October 2015 to January 2016 she became increasingly ill. She would say 'I'm just not a well person'.

'She came back home and was saying 'you can't help me mum, I am too far gone'. We became increasingly concerned about the harm she could cause herself. We felt we were unable to help her.

'At this stage she started talking about suicide and ending her life. In March 2016 her behaviour became so concerning we contacted the crisis team, who said the GP had to contact them. Katrina had started mentioning things like wanting to go peacefully. We became more and more desperate to find a way to help her. Her emotional state was very fragile but she said she actively wanted to get better.

'Due to the lack of care she received her condition steadily got worse.

'Katrina went to her death still not knowing why she felt like she did.'

Mental health trust change system following death

Debbie White, director of operations for NSFT, said the case was 'a sad loss of a young life'.

'We deeply regret that we did not see Katrina following referrals made to our services, and that our attempts to see her were not robust enough,' she said.

'We also regret that not all important information was shared with us by other agencies about the changes and apparent escalation in her mental health in the time leading up to her death. We are confident that this would have triggered us to take more urgent and immediate action rather than continue to consider Katrina to be well enough to be treated as a routine referral.

'A thorough investigation has been carried out at our Trust which has highlighted a number of points of learning.

'As a result, our Trust has implemented a number of changes to improve our services including reviewing our referral processes, increasing access to out of hours crisis care for young people, and looking at how we can better communicate with other agencies to ensure young people needing urgent mental health support get access to that as fast as is possible.

'Once again, our sympathies are with Katrina's family.'