An inquest has revealed that mental health staff were unaware of multiple phone calls made by David Stevens, who expressed suicidal thoughts, before he was treated as low-risk. Stevens, a 57-year-old taxi driver, died by hanging at his home in County Durham. The inquest is examining the “failings” of Tees, Esk and Wear Valley NHS Foundation Trust workers in his case.
Stevens had sought treatment for complex mental health issues, including anxiety, negative thoughts, and hearing voices. Despite making calls to the police, Samaritans, and the crisis team at the mental health trust, the access team responsible for his care remained uninformed. Stevens had previously been referred to the access team in January 2022 after being deemed too complex for another therapy service. The inquest will assess his mental health diagnosis and treatment, as well as any missed opportunities or failings that may have contributed to his death.
The inquest into the death of David Stevens has shed light on the lack of communication between mental health staff and the access team responsible for his care. Despite making multiple calls expressing suicidal thoughts, Stevens was treated as low-risk by the access team, who were unaware of his previous contacts with other services. The inquest heard that Stevens had been discharged from the hospital after an overdose, but neighbors became concerned when they saw him close his curtains the following day. The police were contacted, and upon entering his home, they discovered his body. A pathologist determined that he had died from hanging.
The access team, responsible for low-risk cases, had no knowledge of the calls made by Stevens to other services, including the police, Samaritans, and their own crisis team. This lack of information raises questions about the effectiveness of the communication and coordination within the mental health trust.
The inquest also revealed the interactions between Stevens and the mental health professionals involved in his care. Kay Markwell, a clinician from the access team, described her first meeting with Stevens as positive, stating that she had no concerns about his well-being. She mentioned that he had reported feeling lonely and had struggled with sleep, but he appeared to be in a better state after starting a new antidepressant. Markwell believed that Stevens was looking forward to further sessions and did not indicate a need for additional help.
However, under questioning from the coroner, Markwell admitted that she was unaware of the “bigger picture” regarding the calls made by Stevens to other services. This lack of awareness raises concerns about the thoroughness of the assessment and the overall understanding of Stevens’ mental health condition.
During the inquest, it was revealed that Stevens had made multiple calls to the crisis team and other services, expressing concerns about his medication and thoughts of suicide. Sharon Banbrough, who answered Stevens’ last call to the crisis team, described him as extremely anxious about a social situation and worried about what was being said about him on social media. Banbrough stated that Stevens had responded well to talking therapy and did not warrant a further crisis assessment. However, the crisis team was under significant pressure at the time, with fewer staff than required on shift. This understaffing, combined with the high volume of work, may have hindered the team’s ability to fully assess and address Stevens’ needs.
The inquest also highlighted the miscommunication between hospital staff and Stevens regarding his medication. After his overdose, he was advised to take only seven days’ worth of medication as a precaution against another attempt. However, this information was miscommunicated, leading to frustration on Stevens’ part and threats of legal action. Despite this, the psychiatric clinician who spoke to Stevens after the overdose believed that he showed insight into his anxieties and expressed a desire to continue his treatment with the access team. However, the review conducted after his death identified several issues with his care, including a failure to provide him with new skills or treatments for managing his anxiety.
The scope of the inquest is to examine Stevens’ mental health diagnosis and treatment and determine whether there were any failings or missed opportunities that contributed to his death. The three-day inquest will continue to examine the circumstances surrounding Stevens’ care and the effectiveness of the mental health services responsible for his treatment. The case highlights the importance of effective communication between different mental health services and the need for thorough assessments and follow-up care to ensure the well-being of individuals with complex mental health issues.