Trust's procedures criticised after man's death

Matthew Gale with his twin brother James

A coroner has raised concerns about a hospital's mental health discharge procedures, following the death of a 37-year-old man.

Matthew Gale died by suicide on 19 March 2023, less than two weeks after being released from hospital following his detention under the Mental Health Act.

Writing in a Prevention of Future Deaths Report, Durham and Darlington coroner Simon Connolly said Tees Esk and Wear Valleys NHS Foundation Trust had not made it clear to Mr Gale's family that he should not be left alone following his release.

The trust said it had taken steps to improve communications with families and involve carers during leave.

Mr Gale had a history of mental health issues dating back to June 2017, the coroner said.

He had a schizoaffective episode in February 2023 and was admitted to West Park Hospital in Darlington, according to the report.

Mr Gale was then formally detained under the Mental Health Act on 6 March.

On 8 March, he was granted section 17 leave which allows a patient to leave a hospital, though they can still be recalled.

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But Mr Connolly said the trust did not give a copy of the leave form to Mr Gale's mother and did not tell her that her son should not be left alone.

During the inquest, the trust acknowledged it had not given any such form to Mr Gale's mother and that it had no records detailing the conversations it had with her detailing her son's release.

Ms Gale previously told the BBC: "I don't want somebody else to go through what I am going through."

Matthew Gale was admitted to West Park Hospital in February 2023

The coroner said the trust had removed the need for the person accompanying someone granted such leave to sign a copy of the section 17 form.

This was because the trust had moved to a new digitised system, he said.

"There is risk that future deaths could occur consequent to this change, unless action is taken," he said.

The trust has until 13 September to respond to the coroner's letter, to detail what action it will be taking to address the issues.

Dawn Jessop, deputy chief nurse at Tees, Esk and Wear Valleys NHS Foundation Trust said: "Our thoughts remain with the family and friends of Matthew throughout this difficult time.

"We have taken steps to improve communications with families and involve carers during leave, and will continue working hard to improve the safety of those taking leave from our hospitals."