Mental health staff in Huddersfield missed chances to help a young woman, an inquest heard.
And the poor communication between departments was followed by the tragic death of Sheryl Calcutt.
Ms Calcutt, 34, was found hanged at her home on Glenfield Avenue, Deighton, on May 22, Kirklees Coroner’s Court was told on Wednesday.
Ms Calcutt was diagnosed with bipolar disorder in 2013 and was prescribed medication to control the condition characterised by extreme mood swings.
The mother-of-two was given appointments with a mental health worker but had failed to attend and had stopped taking her medication for two-and-a-half months, the inquest heard.
But staff at South West Yorkshire Partnership NHS Foundation Trust – the mental health organisation responsible for Ms Calcutt – had failed to follow the trust’s procedure for missed appointments, an internal investigation found.
The court heard that while Ms Calcutt’s case had been rated as ‘requiring immediate attention’, contact with her had been infrequent and her records had not been kept up-to-date.
Ms Calcutt’s care coordinator had been given a heavy caseload with 33 patients, many of whom had complex needs, the inquest was told.
And the amount of work had made it difficult for the coordinator to discuss her cases with her manager.
A report following the trust’s investigation concluded that opportunities had been missed, the court heard.
But the court heard that following the report an action plan had been effected to make sure staff were aware of the trust’s missed appointments policy.
A plan was also put into place to ensure care coordinators had regular supervision from their managers and that records were kept up-to-date.
Coroner Mary Burke concluded that single Ms Calcutt had killed herself.
Ms Burke said: “I am satisfied beyond reasonable doubt that Sheryl has undertaken an independent, deliberate act and that consequence was to end her own life.”
Karen Taylor, district director of Kirklees Business Delivery Unit at South West Yorkshire Partnership NHS Foundation Trust, said: “The Trust extends sincere sympathies to those affected by Ms Calcutt’s death. A thorough investigation was conducted at the time and a number of areas for improvement were identified. Action plans have been put in place to ensure we continue to offer safe, high quality services.”