A coroner has said he will request a number of changes following the death of a 25-year-old Ipswich woman who was showing some "hope for the future" and "enthusiasm".
Suffolk Coroners Court concluded the inquest into the death of Gemima Christodoulou-Peace on Wednesday.
The young mechanic who was described by her family and friends as "lovely and bubbly" was found dead in her apartment in Ipswich on July 31, 2023.
Over the course of a two day inquest, evidence was heard from mental health professionals, medical professionals and the police, as well as statements being read from those that knew Miss Christodoulou-Peace.
Senior coroner Mr Nigel Parsley said that she had a "very, very difficult childhood", being raised by her brother, Mert Zabci and her grandmother, before being taken by social services and moving to Ipswich with a foster family.
He also said he was going to write a prevention of future deaths report to send to the Secretary of State for Health after having three concerns.
These are that there is no identifiable system in place that tells a GP that a patient is being prescribed medication that can induce a symptom they have previously suffered from.
In Miss Christodoulou-Peace's case, she was prescribed montelukast, which has a very rare side effect of suicidal thoughts.
Mr Parsley was also concerned that she raised that she was suffering from mental health and anxiety on March 10 to her GP, but it wasn't until July 25 when she had a conversation with the access and assessment team and spoke to a mental health nurse.
Finally he was concerned that there are a limited number of calls within the Norfolk and Suffolk NHS Foundation Trust that are being recorded, with Miss Christodoulou-Peace's call to the AAT not being one of them.
He finished by stating that Miss Christodoulou-Peace's death was on or around July 26, five days before her body was discovered.
On Wednesday, evidence was given by a family friend, Dr Nikki Scheiner, who is also a psychologist.
Picture of Gemima Christodoulou-Peace in 2016 when she was at One Sixth Form College training to become a mechanic (Image: Newsquest)
Dr Scheiner was asked by Miss Christodoulou-Peace's brother, Mert, if she could help his little sister.
She said: "I saw her on July 26 from 11am to 12pm. She started off in a low place because of a lack of progress with her mental health.
"We looked at what she could do for herself and having a routine. I sent her a goal sheet and she was so enthusiastic. I asked her if she wanted to book another session for the next day and she did, but she didn't turn up.
"She had a sense of the future. She knew there was something happening in that she could get therapy for her borderline personality disorder which she had been trying to get.
"She struggled with huge issues of self worth, but this was a young woman who wanted to live and that's what is so devastating."
Detective Sergeant Nathan Hails for Suffolk Constabulary also provided evidence.
On entering the property, the two officers contacted PC Hails, who asked for a forensic team to attend before making the property a crime scene.
Miss Christodoulou-Peace's mobile phone was found on a table in the sitting area, which when looked at, showed that the last outgoing text was to a friend at 12.59pm on July 26 to a friend about a concert.
Also on the phone, it showed that the last call was the Zoom meeting with Dr Scheiner, and her internet search history.
On July 26, 2023, search history showed that she had been conducting research in a short space of time on why some concert bus tickets hadn't arrived, how to find a rescue home for a dog, but also instructions and methods on how to take your own life.
Picture of Gemima Christodoulou-Peace in 2016 when she was at One Sixth Form College training to become a mechanic (Image: Newsquest)
The coroner said the internet history was "interesting" and it could be viewed as evidence that at the time, she was suffering from a fluctuating mood.
The police also checked CCTV for the building, with just one person, a friend of hers whom she had had a relationship with, being the last person to see her, with CCTV capturing him leaving her flat at midnight on July 25.
The inquest heard there had been concerns raised around the individual.
DS Hails said there was no evidence to suggest anyone else was in her building on July 26, but couldn't completely rule out the possibility.
The home office post mortem echoed this, with their being no signs of injuries, no signs of struggle and no physical indication of a third party involvement, however, this couldn't be ruled out by them either.
The post mortem did find that she had 1.2mg per litre of Ketamine in her system.
Following the two day inquest, Mr Parsley gave a narrative conclusion, stating that Miss Christodoulou-Peace died as a result of hanging, but he said there was "insufficient evidence" to prove she meant her death due to her impulsivity which is a symptom in BPD and her intoxication of ketamine.
He thanked those in attendance, and informed her brother, and a family friend who had been present throughout the inquest, that he had pictures he had been sent of Miss Christodoulou-Peace on his desk in front of him throughout.
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