Rebecca Mclellan

NSFT Trust Management 
Norfolk & Suffolk Foundation Trust 
County Hall 
Martineau Lane 
Norwich 
NR1 2DBH 

Date: 16th July 2026 

Dr Sharpstone 
Suffolk Coroner’s Court 

Dear Dr Sharpstone 

Regulations 28 and 29 (Coroners Investigations Regulations 2013) notification made in response to 
the death of Rebecca McLellan 

I write to you in respect of Rebecca McLellan who sadly died on 20 November 2023. Her inquest concluded 
on 25 March 2026, and you subsequently raised a concern within a prevention of future deaths report, issued 
on 18 May 2026. 

Your concern is that: 

There  is  no  documented  system  that  I  consider  adequately  highlights  and  manages  planned, 
prolonged key care co-ordinator absence in the Youth team, nor a formal, documented process that 
clearly and accurately ensures that the roles and responsibilities of named key care co-ordinators are 
adequately  covered  during  periods  of  planned  leave.  There  is  no  process  to  ensure  a  dedicated, 
named care co-ordinator is identified to the mental health patient to provide continuity of care during 
prolonged periods of planned leave. 

As  explained  in the  attached  letter  to  you  dated  13  May  2026  (enclosed),  there  are  specific  processes  in 
place both for planned and unplanned leave. I note your concern set out in the prevention of future deaths 
report, specifically relates to the management of planned and prolonged absence of care-coordinators in the 
Youth Team however. 

Planned,  prolonged  leave  may  include  maternity/paternity  leave  or  planned  sick  leave.  The  process  to 
manage prolonged, planned leave of a care-coordinator in the Youth Team is as set out below: 

-  At the point that a care co-ordinator’s prolonged absence is planned, they will no longer have any 

new patients allocated to them. 

- 

- 

In  advance  of  their  absence,  the  care  co-ordinator  prepares  a  hand  over  of  their  patients  which 
outlines their intervention level.  

In  addition,  at  the  care  co-ordinator’s  supervisions  with  their  line  manager  in  the  run  up  to  their 
absence, there is discussion about the care co-ordinator’s patients and management of the planned 
leave, supported by the handover document. 

-  At MDT meetings, each patient and their clinical need is discussed. In the context of care co-ordinator 
going  on  planned  leave,  these  MDT  discussions  support  the  Clinical  Team  Manager  to  determine 
which patients require re-allocation during the planned leave and which do not.  

-  The  decision  about  re-allocation  is  made  at  the  most  appropriate  time  (based  on  the  patient’s 
presentation at the time and known history), in the lead up to the care co-ordinator’s absence. The 

Trust HQ: County Hall, Martineau Lane, Norwich, NR1 2DH 
Tel: 01603 421421   Web: www.nsft.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 expectation is that a decision will be made for all patients prior to the last two planned visits by the 
care co-ordinator before their leave. 

- 

Individual  patients  are  notified  by  their  care  co-ordinator  of  the  plans  to  manage  their  absence  in 
advance. How that is done will be dependant on what is most appropriate for the patient, but when a 
decision is made to re-allocate a patient to a new care co-ordinator, they are notified of this at the 
penultimate appointment with their usual care coordinator. Then the final appointment before the care 
co-ordinator’s leave is a joint appointment with the original and the new care coordinator to support a 
positive transition between staff. 

To ensure the process is documented and applied consistently across all community services, the Trust has 
prepared and ratified a guidance note for staff (enclosed).  

Rebecca’s tragic death has brought about change within the Trust, as set out in the evidence provided to the 
Court by 
, Director of Nursing and Quality for East Suffolk, both during the inquest 
and subsequently. We trust that the above information addresses your concern. 

Finally, I wish to join my colleagues in offering our deepest condolences to Rebecca’s family and friends for 
their tragic loss.  

Yours sincerely, 

aro ne onovan

Chief Executive Officer 

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Director of Nursing & Quality 
 East Suffolk Locality 
Mariner House 
43 Handford Road 
Ipswich 
IP1 2GA 

Date: 13 May 2026 

Dr Sharpstone 
Suffolk Coroner’s Court 

Dear Dr Sharpstone 

Rebecca McLellan Inquest 

I refer to your letter sent by email on 6 May 2026 and am grateful for the confirmation of your views in 
relation to PFD regarding each of the matters set out.  

As indicated in the Trust's legal team letter on 6 May 2026, the Trust were not aware that you had an 
ongoing concern in relation to the management of key staff vacancies and absent staff in the Youth team. 
As such we would be grateful if you would consider the information below, as the Trust considers there is a 
system in place that addresses the ongoing concerns you have.   

1.  E-roster: this an electronic platform which holds all shifts across the Trust so that it is easy to see 
who is working and who is not at any given time to enable planning. Oversight of the E-Roster is 
undertaken by the Operational Manager and Community Team Manager identify gaps, manage staff 
absence, book additional temporary staff and provide an overview of how many hours a day each 
team has to manage capacity.  

2.  Team off duty chart: this is a chart of all staff within the team, noting who is on and off duty, on leave 

(of any type, planned or unplanned) at any given time. It also records who is responsible for 
covering the duty role (availability for urgent calls and referrals) on each day, and who is covering 
for staff that are off. This chart is held in the Youth Team Microsoft Teams channel to enable all staff 
who are working on and off site to access it quickly.  The chart is created 2 months ahead of time 
and updated by the team administrator whenever there are reported absences or changes.   

3.  Daily huddle: This is a team meeting that takes place every morning and where any staffing 

and absences can be acknowledged and the team informed of any cover requirements. The off duty 
chart is then updated by the team administrator. 

4.  Early Warning Trigger Score (EWTS) Audit: this is a monthly audit providing a structured approach 
to the early identification of quality risks within a clinical team. Upon completion of the audit, a 
Trigger Score is calculated. The Community Early Warning Trigger Tool has 25 indicators to 
categorise the team capacity including vacancies, sickness, complaints, leadership post filled, 
medic posts filled, and more. This supports managers to recognise the risk within their team and 
escalate as necessary for support with staffing. The EWTS is used in conjunction with Clinical Audit 
outcomes, financial oversight and key performance indicators, and is a tool used across the Trust.  

Trust HQ: County Hall, Martineau Lane, Norwich, NR1 2DH 
Tel: 01603 421421   Web: www.nsft.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 5.  Check and Challenge for the staff roster: this includes monthly review by Associate Director of 

Nursing for community of the E-roster in relation to anything that may impact on team capacity (for 
example staff vacancies, sickness, planned leave). This regular review began in April 2026, to 
ensure we are looking ahead as well as at the current capacity to enable planning of team capacity.  

6.  Unplanned leave process: When a care co-ordinator is on unplanned leave (sickness), their patient 
clinic appointments are reviewed by the Community Team Manager (CTM) and team administrator. 
They then re allocate the appointments to another clinician or rebook them, depending on: predicted 
length of sickness absence, clinical risk and the intervention need of the patient. When sickness 
becomes long term, this managed by the CTM who reviews the staff member’s caseload and 
reallocates to the rest of the team based on the patients’ acuity and intervention levels. There is 
also a fortnightly allocation meeting which takes place to allocate new patients but can also be 
utilised to discuss and re-allocate patients whose care co-ordinator is on long term absence.  

7.  Planned leave process: When a care co-ordinator is due to go on planned leave, they prepare a 

hand over of their patients, outlining their intervention level and which patients require reallocation 
to cover their absence. Patients are notified that their usual clinician will not be present for their next 
appointment and they may see a different clinician. Patients are also informed to call the duty 
worker and refer to their safety plan if they need support when their care co-ordinator is on leave. 
For patients who are receiving specific clinical interventions from their care co-ordinator, their care 
may be paused until the staff member returns. This is only where it is a specialist need and this is 
done with the patient’s consent and input.  

8.  Staff shortages due to vacant posts are highlighted through the EWTS audit putting in context the 

impact of vacancies alongside staff sickness. If the EWTS demonstrates a high score, it can trigger 
consideration for Business continuity for the team, reviewing capacity and what activity can be 
undertaken within the resources available. This would also be recorded as a risk on the trust risk 
register to highlight the increased risk in the team. The East Youth Team EWTS is currently 5 which 
would not trigger concern for the teams capacity. When staff leave, their posts are reviewed to see if 
the role and grade of that post meets the needs of the service or requires amendment. Posts then 
go through an approval process within the Trust before being advertised on NHS Jobs website and 
recruited to. We ensure a service user is involved with recruitment by participating on the interview 
panel also.  

There are a number of policies relevant to the management of staff absence and vacancies, as follows:  

1.  Annual leave policy 

2.  Sickness absence policy  

3.  Rostering policy (which provides clear parameters for the production of rosters for all wards and 

departments) 

4.  Engagement and use of Temporary Workers including Medical Locums policy  

5.  Transfer policy (which sets out expectations and guidance in relation to safe transfers of care, 

including in relation to staff changes and sickness) 

6.  Supporting and Managing Attendance policy (which promotes and supports staff in minimising 

absence from work) 

7.  Trust Business Continuity Management Plan policy 

The Trust have considered the lack of care coordinator in this case and since then, the E-roster, off duty 
chart, Check and Challenge and EWTS are all now in place to allow for a better continuation of care 
despite both planned and unplanned staff leave. 

Page 2 of 3 

 
 
 
 
 
 I hope that this further information will assist you in consideration of whether to issue a PFD, or in the 
drafting of the PFD. If you require any further information, I would be very happy to provide it. 

Yours sincerely, 

Director of Nursing & Quality, East Suffolk Locality 

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