The death of a 'much-loved' market trader has seen changes introduced to the way private referrals to the region's NHS mental health teams are made.
Malgorzata Szwed, 35, from Cawstons Meadow, Poringland, died on September 15 last year.
She was found in a field in Arminghall, on the edge of Norwich, and the medical cause of death given in a post mortem examination was asphyxia due to hanging.
An inquest into her death was held at Norfolk Coroner's Court in Norwich on Tuesday, and heard that Miss Szwed had met a friend for a drink on the night she died.
She had recently opened a new tattoo and piercing stall on the market, having previously run a tea and coffee stall there.
Polish-born Miss Szwed, who the inquest heard loved rock climbing and the gym, had bumped into another friend on her way home.
But her partner became worried when she still had not arrived home some time later and called the police, who began a search for her and, as concerns mounted, tracked her phone to a route she would normally take to cycle home.
Her body was later found by officers.
The inquest heard that Miss Szwed had a history of mental health problems and had been supported well by a private therapist and her local GP.
But it heard her mood was often "impulsive", and she had once been referred onto the Norfolk and Suffolk NHS Foundation Trust (NSFT), though she had declined an assessment.
Despite the limited contact, the NSFT launched an investigation into her death, which recommended a new protocol which would enable referrals to be made directly from private healthcare providers to mental health teams, rather than needing to go via a GP.
Area coroner Yvonne Blake said she supported the protocol.
Ms Blake recorded a narrative conclusion in the inquest, and said: "[Miss Szwed] took her own life, however she was intoxicated at the time and taking psychoactive medication and her ability to form the required intent was impaired."
She expressed sympathy to Miss Szwed's partner, and said it was clear she had been a "much-loved person".
A spokesperson for NSFT confirmed they had widened the routes via which referrals could be made, and said the changes had been introduced in December 2019.
For support, contact the Samaritans on 116 123.
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