Review of mental health services finds failings after woman’s death, inquest hears

Beacon House, Coroners Court in Ipswich

Beacon House, Coroners Court in Ipswich

A review of mental health services has concluded that more could have been done to help prevent the death of a 31-year-old woman, an inquest has heard.

Gemma Stone, who suffered from depression, anxiety and stress, hanged herself after going missing from her mother’s home.

Today (Monday) the inquest at Suffolk Coroners Court, in Ipswich, was told that issues which meant Miss Stone did not get all the help she needed had been identified in an official review.

The body of Miss Stone, of Frizzlers Green, Cobbs Hall Lane, Great Saxham, was found hanging from a tree in Church Lane, Dalham on November 16 last year, the day after she had been reported missing.

Nearby was her car in which police found 25 handwritten letters and cards.

They were addressed to family members and friends, telling them that she loved them and apologising for her actions.

The inquest heard that Miss Stone had been referred to Suffolk Wellbeing Service for support.

They arranged for her to see a counsellor at a partner organisation.

However, when a counsellor realised that a higher level of support was needed, problems were encountered in trying to obtain it.

These included phones not being answered and confusion about where to get more help.

Assistant Suffolk Coroner Dr Daniel Sharpstone, referring to the findings of a review conducted by Suffolk and Norfolk NHS Foundation Trust, said that additional level of support was never provided.

The review concluded that if more help had been provided, Miss Stone’s mental health may have improved and her death may have been avoided.

Dr Sharpstone described the review as ‘full and honest’.

Since Miss Stone’s death, a number of changes have been instituted in an effort to avoid a repeat of the same failings, the inquest heard.

Dr Sharpstone said: “It is apparent that the support given to Gemma was below what might be reasonably be expected.”

He recorded a conclusion that Miss Stone took her own life.

Dr Sharpstone said: “I have no doubt that here is a very passionate young lady and a very caring young lady who experienced significant social distress.

“I am also clear that she fully intended and forsaw the consequences of her actions.”