Mental health staff did not properly follow policies during the treatment of a Lynn woman, who later died following a drug overdose, an inquest has heard.
Norfolk coroner Jacqueline Lake concluded the failings were unlikely to have contributed to the death of Naomi Twiddy, 34, last summer, during a hearing on Friday.
But she has called on the Norfolk and Suffolk NHS Foundation Trust (NSFT) to inform her of the steps it will take to address the problems.
And Lesley Workman, an acting service manager who took part in the trust’s own investigation into the case, said: “Lessons will be learned.”
Miss Twiddy, who was of no fixed abode, died in the Queen Elizabeth Hospital on July 25 last year, almost two weeks after she collapsed at a flat in South Everard Street.
The inquest, which was held at the town’s magistrates court, was told she had taken heroin shortly before she collapsed and had complained of feeling unwell.
The medical cause of death was a hypoxic brain injury, linked to cardiac arrest which was triggered by a drug or alcohol overdose.
Miss Twiddy had a long history of drug and alcohol problems, as well as mental health issues.
The court heard she had been reluctant to engage with support services while she was being treated in a mental health unit in February 2016 and declined further offers of help after she was discharged.
Members of her family, who were present in court, said they knew she was “troubled” and were not looking to blame anyone for her death.
But an internal investigation by the trust showed incidents in which policies were not followed, such as when Miss Twiddy was late returning to the ward following a period of leave.
The hearing was told that while there was no evidence to suggest the procedures were not followed, there was also none to show they were.
There was also a week-long period after Miss Twiddy was discharged in which no attempt was made by staff to contact her at all to arrange follow-up appointments.
Earlier efforts to trace her had failed as a phone number they had for her was not in use. Although she had been in contact with her father following her discharge, Miss Twiddy declined his offers of help and threw a letter inviting her to an appointment away, the court heard.
And an audit of discharge records showed that, of the last 10 patients to be discharged from the ward in which Miss Twiddy was treated, none of their records met policy requirements.
Vanessa Wragg, the trust’s general services manager for acute services, said: “I’m led to believe it’s a trust-wide problem, so I’m going to escalate it to our service forum. The policy itself may need to be reviewed.”
Concerns were also raised about a lack of contact by staff with Miss Twiddy’s family.
Mrs Lake, who concluded that Miss Twiddy’s death was drug and alcohol related, asked to be notified of the measures taken by the trust to address the failings revealed.
Copies of the letters will also be given to Miss Twiddy’s family.