“as follows:It was heard in evidence that since Kerry’s death the Norfolk and Suffolk…”

The coroner’s concerns

as follows:It was heard in evidence that since Kerry’s death the Norfolk and Suffolk Foundation Trust have conducted a review of their treatment provision for individuals suffering from Borderline Personality Disorder (BPD). As a result of this review the Norfolk and Suffolk Foundation Trust are planning to move the Borderline Personality Disorder Service treatment in-house rather than using external providers and will provide Dialectic Behavioural Therapy This change is currently in the planning stage and at the hearing I formally requested an update when these plans are put into practice. The update is to include details the new policies and procedures in place regarding clarity of communication of information given to those suffering with BPD, the training and development of Norfolk and Suffolk Foundation Trust staff in relation to BPD and the undertaking of formal risk assessment and the completion to the requisite documentation in cases of those suffering with BPD. During the hearing itself evidence was heard from an expert witness ) about one of the facets of those suffering from BPD which was not addressed by the NSFT plans. Under the proposed new system, in order to access the Norfolk and Suffolk Foundation Trust Borderline Personality Disorder service, those suffering from the condition would have to agree to be transferred for treatment under the Norfolk and Suffolk Foundation Trust Integrated Delivery Team for onward referral to the new bespoke service. However, explained that the majority of individuals with a diagnosis with BPD will have had significant previous contact with their mental health service providers. Kerry herself, had had significant history of previous treatments over a number of years (including Cognitive Behavioural Therapy, Cognitive Analytical Therapy, antidepression medication and anti-psychotic medication), none of which had proved effective. confirmed that none of these treatments would have been likely to have had a positive therapeutic effect, which in itself would compound the nature of BPD itself. explained that the cycle of being offered ineffective treatment would enhance the loss of hope and optimism which is a feature of BPD. Another facet of BPD was often an avoidant personality making sufferers unwilling or unable to engage with new individuals or teams. This being the case, I am concerned that the proposed requirement in the Norfolk and Suffolk Foundation Trust plan (which will require a BPD suffer to agree to a transfer to an Integrated Delivery Team before being placed onto the new service) may prevent some patients gaining the access to the treatment they clearly need.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2019-0137

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0