An inquest has revealed that failures within a mental health trust may have contributed to the suicide of a man several months later. David Stevens, a 57-year-old taxi driver from Willington, was found dead at his home on June 15, 2022, while awaiting treatment from the Tees, Esk and Wear Valley Trust. The assistant coroner, Janine Richards, will examine any missed opportunities in his treatment.
David Stevens had been diagnosed with dysthymia and a paranoid personality disorder. He reported experiencing auditory hallucinations and extreme anxiety. He was referred to the trust’s access team on January 25, which provides support to individuals at low-risk of self-harm or suicide. However, a review uncovered several shortcomings in his care. His first formal therapy session was not scheduled until June 21, despite undergoing phone and in-person assessments. During May and June, he made 15 calls to the trust’s crisis team, which was severely understaffed at the time. He expressed concerns about internet scams, social media, severe sleep deprivation, and his prescribed medications. He also sought help at the emergency department twice, once due to suicidal thoughts and again after taking an overdose.
Lynn Lewendon, a nurse with the North of England Commissioning Support, conducted a serious incident review. She identified multiple issues in his care, including delays in initiating “active” treatment. According to Ms. Lewendon, if Mr. Stevens had survived until his appointment on June 21, he would have waited 21 weeks for full treatment to commence. The access team argued that his treatment had already begun at the assessment stage, but Ms. Lewendon suggested that starting full treatment earlier might have made a difference in his case.
Furthermore, no comprehensive assessment was made of Mr. Stevens’ repeated calls to the trust’s teams, which should have triggered a reassessment of his care plan and level of risk. A thematic review conducted by the trust seven months prior to Mr. Stevens’ death also revealed shortcomings that could have potentially contributed to his death.
Sharon Salvin, a director at the trust, informed the inquest that significant improvements had been made since the incidents occurred. The crisis team had exited special measures in June 2023, and the backlog of cases had been reduced from 80 to 10. However, Ms. Salvin acknowledged the extreme pressure the trust had faced at the time and stated that multiple changes had been implemented to address the situation.