Durham and Darlington Crisis Team: Coroner finds missed opportunities in death of David Stevens
3 November 2023
David Stevens, who had been diagnosed with Dysthymia and Paranoid Personality Disorder, died in June 2022 following a deterioration in his mental health. The inquest into his death recently took place before HM Assistant Coroner for Durham and Darlington, Janine Richards.
During the course of the inquest, evidence was heard showing that David made numerous calls to Tees, Esk and Wear Valley NHS Trust (TEWV) mental health services for help in the months before he died, including the Access Team and Crisis Team, as well as to his GP and police. On some days, he called the Crisis Team multiple times. He also presented at A&E on three occasions with suicidal thoughts. However, he did not receive any formal treatment in this period.
The court heard that the TEWV Crisis Team was in business continuity mode when David came into contact with services. As a result, there were not enough staff to meet demand at the relevant time, unregistered and unqualified staff were triaging patients and poor assessments were made of David’s needs on several occasions.
A thematic review had been completed by the trust in relation to the deaths of four patients in 2021 following contact with the Crisis Team. The coroner found that a number of the concerns raised in that review were apparent in the care provided to David the following year. This included underuse of the crisis triage tool, concerns in relation to risk assessments and safety planning and lack of communication between services.
The coroner found that although David had been in contact with a wide range of agencies, no one had the full picture of his anxiety, the difficulties he was experiencing, and issues around his medication. Each of his contacts with services was viewed in isolation and as a result, assessments were based on a fractured picture of his needs and risks.
The coroner also found that the plan for David’s treatment was not in accordance with NICE Guidelines for the management of generalised anxiety disorder and panic disorder in adults, that there were a number of missed opportunities for his overall picture to be considered and that David’s contact with services did not address the underlying causes of his anxiety.
HM Assistant Coroner Richards concluded that David died by suicide. She also recorded that he was still awaiting treatment to address his mental health difficulties at the time of his death and there had been ‘a multiplicity of issues in relation to his care’.
Media coverage of the inquest can be found below:
- Patient called Durham and Darlington crisis team 37 times before death
- David Stevens death: Coroner hears known NHS failings
- David Stevens’ death: Known NHS failures may have contributed
- TEWV knew about crisis team issues months before man’s death
- David Stevens inquest: Family say suicide of County Durham man was ‘needless’
- David Stevens’ death: Coroner finds missed opportunities.
The inquest into the death of Linda Banks, who died nine weeks before David Stevens, following contact with the same TEWV Crisis Team, is listed for three days at Durham and Darlington Coroner’s Court on 21st November 2023.
Lily Lewis, of GCN’s Inquests & Inquiries team, represents the families of David Stevens and Linda Banks. She is instructed by Alistair Smith and Lucy Wennington of Watson Woodhouse Solicitors.
The families of David Stevens and Linda Banks, along with other bereaved families, are campaigning for a public inquiry into TEWV. See recent coverage of the campaign here.
