Norfolk and Suffolk Foundation Trust 'did not update GP'
A mental health trust treating a 15-year-old girl with anorexia failed to keep in touch with her GP or keep full records, a report states.
Ellie Long, 15, was found hanged in her room in Wymondham, Norfolk, in 2017.
Norfolk and Suffolk Foundation Trust (NSFT) was told to take urgent action by Norfolk coroner Jacqueline Lake.
Responding to her newly-published report, the foundation trust said it was introducing new training for staff on record keeping and communication.
An inquest in January heard the trust had not been aware of Ellie's historical suicide risk, a care plan had never been completed and there was no crisis plan.
The coroner concluded she may not have intended to take her own life.
In March, Mrs Lake said she was not satisfied with the trust's response over two issues - record-keeping and communications with outside agencies - and made a "prevention of future death" report to the chief executive of NSFT.
The report says an initial updating letter was sent to Ellie's GP, but another letter was written and not sent and nothing further was shared with the GP by letter, phone or email.
There was no evidence that the trust had tried to contact Ellie's school.
The report states: "Sharing of information and communication with external agencies is a matter which as been raised with NSFT on previous occasions."
Mrs Lake also pointed out that trust's response that it would "remind staff of the importance of recording efforts to share information" may not be sufficient to prevent future deaths.
She stated it was the importance of sharing information and communicating that needed to be addressed.
Regarding record-keeping, Mrs Lake said not all records were entered into the electronic system, with some handwritten notes from meetings only coming to light at the inquest.
She said she recognised NSFT had taken some action with staff, but she added: "I have concern that full record keeping and disclosure requirements will not remain a priority."
In November, NSFT was rated inadequate for a third time, making it England's worst-performing mental health trust.
Its chief executive at the time of the inquest and report, Antek Lejk, stepped down in March after less than a year in post.
Diane Hull, Chief Nurse of the NSFT, said: "We would again like to express our condolences to Ellie's family and friends. Her death was a tragedy and it is essential that we take every opportunity to not only learn but to act in a way which ensures improvement."