During the course of the inquest, the mental health care Ms McLellan received from the Norfolk and Suffolk NHS Foundation Trust was called into question. A week later, Ms McLellan presented to NSFT’s offices in considerable distress. Dr Sharpstone heard that Ms McLellan had no care co-ordinator for approximately nine weeks, partly due to staff shortages. The Trust added that individual patients are notified by their care co-ordinator of the plans to manage their absence in advance. He continued: “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.