A health trust has pledged changes in care after the suicide of an "empathetic" and "kind-hearted" Ipswich woman who suffered with years of mental health issues.
Sarah Peart took her life on August 14, 2020, after battling emotionally unstable personality disorder and bulimia for several years.
The inquest into the 30-year-old's death concluded on Thursday, March 18, at Ipswich Coroners' Court.
Sonia Peart, mother of Sarah, told the court her daughter had a happy childhood, was "extremely intelligent and fiercely loving", but went through difficult circumstances in her adolescence when her father died.
"She was an extremely caring person," Mrs Peart said. "The last time I saw her was at a birthday party on Saturday, August 8. We were singing and doing karaoke, it was wonderful.
"She was so talented, bright, shiny, sparkly — I would ask her 'what do stars do? They shine'."
Sarah received therapy from the Norfolk and Suffolk NHS Foundation Trust (NSFT) for four years, but decided that she no longer wanted to go ahead with it and self-discharged in February 2020 — something her family said should have been a red flag.
Despite being referred by her GP for specialist help in April — and at several meetings since then — at the time of her death in August Sarah had not yet accessed specialist care.
The inquest was told that the NSFT offered its sincere condolences to Sarah's family and has since examined the timeline of events which led up to her death.
The trust has pledged to strengthen communications regarding referrals to stop people being moved from one service to another, and acknowledged the trust should have initiated a referral for specialist care in Sarah's case.
The trust said communication with the families of patients will be improved as a result and a new service Dial Up Plus will keep patient's better informed about the progression of their care.
Assistant coroner Tim Deeming recorded a narrative conclusion to Sarah's death.
He added: "Specialist care was required and at the time of her death this had not been provided."
Sarah's family added they thought her suicidal thoughts should have sparked more of a response from care providers and mother Mrs Peart told the court she had been saving thousands of pounds to get her daughter private help.
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