MENTAL health workers in York have been told to improve their communication with each other, after a woman they were caring for took her own life.

Anna Hoynes, also known as Gillespie, died last May and her body was found on railway tracks near Copmanthorpe.

At an inquest on Thursday, coroner Rob Turnbull heard about a Serious Untoward Incident Report prepared by TEWV, the health trust responsible for mental health care in York. It included 14 recommendations for improvements after Anna’s death.

Anna, then 40, was being looked after by the intensive home treatment team. She had been referred after an earlier suicide attempt, but on the night she died, Anna had phoned for help and spoke to someone from the crisis team.

Her family said they were angry health workers did not go to see her that night, even though she was very distressed. Her dog, who had been very important to her, had been put down that day; and she had a history of suicide attempts.

TEWV’s locality manager for York, Neil McAdam, told the inquest procedures were being changed to make sure the crisis team - which works 24 hours - and the home treatment team share information.

He also said they were trying to make it easier for health workers to get hold of records, which were very fragmented after years of changing NHS bodies. He said they had spoken to all staff about how important much-loved pets can be.

The report also looked at “missed opportunities” to see Anna face-to-face, and the fact that someone could have seen her the night she died.

Anna’s mother Wendy Hoynes spoke at the hearing about her daughter’s youth in York, describing her as a bright child who achieved a lot at school and work.

Anna had been a talented pianist as a child, Mrs Hoynes said, and had lived for dogs and cats including her beloved Rottweiler Jaspar, who had been put down the day she died.

Mrs Hoynes spoke of her frustration that through years of mental health problems, including suicide attempts, Anna did not seem to get the help she needed until just before her death.

The inquest also heard that in the weeks and months before she died, Anna had been frightened by threats from her estranged husband Lee Gillespie, and worried about having to appear in court beside him.

Giving his conclusion of suicide, Mr Turnbull said: “There are findings in the Serious Untoward Incident Report which cause me concern - around the communications between different aspects of the health services. I am pleased to hear they are being and have been addressed.”

He added: “This is such a distressing case, because clearly she had a supportive family if she had only been able to fully open up to them and ask for assistance.”

Evidence also came from a British Transport Police officer called to Copmanthorpe, by a train driver who had seen Anna’s body on the line.

Since the inquest, the health trust’s Ruth Hill, director of operations for York and Selby, has issued a statement saying: “We are deeply sorry that Ms Gillespie died while she was under our care.

"Whilst we cannot change what happened, we have carried out a thorough investigation into the incident and a number of recommendations have been highlighted and are being progressed.”

It is the second time in recent weeks that mental health services in York have been criticised over the death of a patient.

Last month, the family of Anthony Pratt told how he had begged in vain for help, before taking his own life. An investigation into his death has been launched.

  • If you are concerned about someone or have any thoughts about suicide, phone The Samaritans on 116 123.