A coroner is to raise formal concerns that a mental health trust is failing to keep patients safe.

Coroner Nadia Persaud will file a report after an inquest into the death of Louise Allen on June 13, 2021.

The inquest on July 4 and 5 heard persistent signs that Louise might take her own life – including that she was researching methods online – were not acted on.

Her family described her treatment by the North East London NHS Foundation Trust (NELFT) as “unforgiveable”.

The trust serves Barking, Dagenham, Havering, Redbridge, Waltham Forest, Essex and Kent.

Workers testified last week that staff shortages are causing unmanageable caseloads and NELFT said it will reflect on the coroner’s findings to continue improving.

Ms Persaud read from a NELFT report that two care coordinators had given up Louise's case “because they were struggling with the number of complex cases they were juggling."


Born at the Royal Free Hospital, Louise grew up in Camden, the court heard.

Her family described her as a “sweet-natured and happy little girl”.

But in her late teens, a psychologist testified, Louise was sexually assaulted.

She battled the resulting trauma for the rest of her life and was eventually diagnosed with bipolar disorder and emotionally unstable personality disorder.

Louise sought treatment, became a primary school teacher and bought a flat with her sister in Hawker Place, Walthamstow.

She had a “major breakdown” in 2020, her family said, and spent eight months in Goodmayes Hospital, Ilford, before being sent home.

“Not good enough”

“Straight away, we could see that the quality of care she was getting was not good enough,” Louise's family said.

She should have had weekly visits from her new care coordinator, but had just five in 18 weeks.

Her records were repeatedly updated to say there was no change in her mental health, despite no assessments taking place.

Additionally, Louise’s family and carers were raising constant concerns that her health was deteriorating.

Ms Persaud said a care firm which visited Louise daily was “excellent” and repeatedly raised concerns with NELFT, which were not acted on.

Louise's family’s calls and emails went unanswered. They were so concerned that they wrote to Walthamstow MP Stella Creasy.


Psychologist Jacob Lawrence testified that during the Covid-19 pandemic, there was a shortage of care coordinators and “caseloads really were too high”.

But even before the pandemic, one of Louise’s coordinators had given up her case due to an unmanageable workload.

Dr Lawrence said NELFT had a high staff turnover and recruitment was difficult because it paid less than other trusts.

Robin Sookhan, an assistant director, said NELFT still didn’t have enough staff.

“We are given a financial budget every year, but clinically what we need is more than what we currently are financially having,” he testified.

He said NELFT now employed more staff than its budget allowed – but even that was not enough.

“There is a shortage of social workers, occupational therapists, even doctors,” he said, agreeing that it was partly due to low wages.


Ms Persaud found Louise took her own life after she “did not receive the care that was necessary to protect her from the high risk with which she presented”.

She recorded a narrative conclusion and will send a Prevention of Future Deaths report to NELFT and the Care Quality Commission (CQC).

The next day (July 6), Ms Persaud held the inquest of Robert Burills from Harold Hill, who also took his own life.

He was supposed to be “closely monitored” by NELFT but received no contact for nine weeks.

Ms Persaud told his family she was concerned NELFT did not have the resources "to provide a safe service" and she would share the results of her report with them.

“We cannot say that our dear Louise would still be alive today had she had proper treatment for her diagnosis,” said her family.

“But at the very least she should have received that treatment and she never did... NELFT needs to be held to account for this."

NELFT offered “heartfelt condolences” to Louise’s loved ones.

“The trust will further reflect on the coroner’s findings at the inquest to ensure that the quality of care at the trust continues to improve,” it said.

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