A mum died by suicide just weeks after making mental health crisis calls that were not properly followed up.

Nicola Norman, 42, was found dead at her mother's house on January 20, 2020, an inquest was told.

Ms Norman was diagnosed with emotionally unstable personality disorder and suffered a sharp decline in November 2019, developing depression, anxiety and somatisation - experiencing psychological distress in the form of apparently physical symptoms,

On December 21, 2019, she phoned the local NHS trust's Single Point of Access number, a 24-hour phone line to support people in a mental health crisis in Brent, Harrow, Hillingdon, Kensington & Chelsea and Westminster.

She was in a highly anxious state and told the operator that she had had enough of life and felt like a burden, Inner West London Coroner's Court heard.

Ms Norman then disconnected the call, but the operator did not call back.

Ten days later, on New Year's Eve, she phoned the number again and informed an operator she had taken an overdose and cut her wrists in front of her son.

The operator told her to ring primary care mental health services, as she was already under their care.

She was not put through to this service by the operator, and there were no concerns passed on to any other services or to her GP.

Each call was answered by administrators with no clinical qualifications.

In court, a service manager at Central and North West London NHS Foundation Trust said that staff should call back if calls are cut off.

They also said that Single Point of Access operators now use "warm transfers" for calls such as that made by Ms Norman on New Year's Eve.

This involves the operator transfering the call to a colleague rather than leaving the patient to make another call, and passing on any relevant information so that the caller doesn't have to repeat themselves.

Senior coroner Prof Fiona Wilcox raised concern that Single Point of Access calls are not routinely discussed with or passed on to supervising clinicians, and the patient’s GP or mental health services were not notified of the call.

Prof Wilcox called on Central and North West London NHS Foundation Trust to take action to prevent future deaths.

When life is difficult, the Samaritans is available 365 days, 24/7. Call for free on 116 123, email jo@samaritans.org, or visit www.samaritans.org.