For any parent, the agony of losing a child is the worst pain imaginable.

To then have to find the energy to fight a system buckling under pressure is surely the last thing you would want to do – but this is precisely what Rebecca McLellan’s family did.

“It feels like, as a parent, it is difficult enough to lose a precious child under any circumstances,” said her mother, Natalie McLellan. “To lose them and know they have suffered failures makes it more difficult.

“To fight for answers is traumatising and I’ve been left feeling like her life didn’t matter to them; but she mattered to me.”

Rebecca McLellan was 24 when she died. (Image: McLellan family)

Rebecca McLellan’s family, with her mother Natalie pictured front left, gathered outside the coroners’ court. (Image: Newsquest)

Becca, as she was known to friends and family, was 24 when she died by suicide, having been under the care of the Norfolk and Suffolk NHS Foundation Trust (NSFT) after being diagnosed with bipolar disorder.

An inquest into Ms McLellan’s death heard she was left without a care co-ordinator after the person assigned to her went on planned, prolonged leave on May 31, 2023. A week later, Ms McLellan presented to NSFT’s offices in considerable distress.

However, she was told that if she did not leave, staff would call the police. This encounter was filmed by Ms McLellan and showed at the inquest .

Rebecca McLellan was employed by the East of England Ambulance Service. (Image: McLellan family)

Yesterday, coroner Daniel Sharpstone wrote to NSFT raising concerns at the risk to further lives.

He referenced the length of time Ms McLellan was left with no care coordinator and staff shortages, with the ‘Youth’ team having four vacancies in a team of 16 at the time.

In a prevention of future deaths report dated July 18, Dr Sharpstone said there is no adequate system to manage planned, prolonged absences of key care co-ordinators in the Youth team, nor a clear process to ensure their responsibilities are covered.

He added there is also no process to ensure a named care co-ordinator is identified to provide continuity of care during such periods.

Anthony Deery, Chief Nurse at NSFT, said the Trust is “deeply saddened” by Ms McLellan’s death and that their thoughts continue to be with her family.

However for the family, this comes far too late.

“You’ve tried to fix your reputation before addressing the issues that made [NSFT] the worst mental health trust in the country,” said Mrs McLellan.

NSFT has previously been ranked as the worst performing mental health trust in the country.  Data released by NHS England for 2025/26 ranked it as third worst .

Mrs McLellan continued: “Things can go wrong, mistakes can happen. But you have to be able to turn around, admit those things and have a want and intention to want to make things better and the attitude from the trust is saying different.

“Some things might be improving, but the basics were not a priority.”

Following her daughter’s death, Mrs McLellan joined the committee for The Campaign to Save Mental Health Services in Norfolk and Suffolk. The campaign said it is still finding “the same issues in local deaths this year that were in prevention of future death recommendations years ago”, as well as issues raised by bereaved relatives that have not been addressed.

Mrs McLellan continued: “From a family perspective, the whole process has been really traumatising.

“We’ve been through the worst trauma you could go through – then we had to fight for action.”

Speaking on behalf of NSFT, Mr Deery said: “We have carefully considered the concerns raised by the coroner and have responded in detail, setting out both the processes already in place and the further improvements we have made since Rebecca’s death. These include strengthening our arrangements for managing planned and unplanned staff absences, introducing clearer guidance to ensure continuity of care, and improving oversight of caseload management across our community teams.

“Alongside the wider improvements made following our investigation, we remain committed to learning from this tragic case and taking all necessary steps to deliver safer, kinder and better care for the people who use our services.”