David Stevens death: Coroner hears known NHS failings

A full inquest will be held at Crook Coroner's Court at a later date

Failings found in a mental health trust after the deaths of four people may have contributed to a man's apparent suicide months later, a coroner heard.

David Stevens, 57, was found dead at his home in Willington, County Durham, on 15 June 2022.

His family said the Tees, Esk and Wear Valley NHS Trust failed to judge the risk he posed to himself.

The trust said there was individual "negligence" but not systemic failures. A full inquest will be held later.

At a pre-inquest review held in Crook, Durham assistant coroner Janine Richards heard Mr Stevens had a history of mental health issues that escalated in May and June 2022.

On 13 June he was taken to A&E after taking an overdose, but he was discharged and told to make an appointment with a GP to discuss his mental health further.

He was found dead two days later.

'Silo working'

Lily Lewis, representing Mr Stevens' family, said it was "at least arguable" there was link between "deficiencies in his care and his death".

She said a review carried out by the trust in 2021 following the unexpected deaths of four patients identified a number of problems which were still of relevance to Mr Stevens' death some eight months later.

These included "fragmented communication" between the various teams Mr Stevens had contact with and a failure by the trust to create a full and "coherent" picture of his risk.

She said it was "clear" there was an "emerging picture of risk developing" and Mr Stevens was becoming "overwhelmed and anxious", having paranoid thoughts and showing early warning signs of psychosis.

Ms Lewis said he had multiple contacts with the trust's access and crisis teams as well as other health professionals but because of "silo working", no full picture was ever produced of his risk and vulnerability.

Jamie Mathieson, representing the trust, told the pre-inquest review action plans had been drawn up to address the problems.

He said just because a system "may be prone to failure" due in part to the "inherent complexity" of it and difficulties faced by staff who were ultimately "human beings", that did not mean there was a "systemic failure".

He said at the time of his death, Mr Stevens was in the community and not "detained" by the trust, and while he was vulnerable and a risk he was not "exceptionally" so.

He also said action plans had been drawn up to address the failures.

'Not getting right help'

Ms Richards said the problems identified by the 2021 review appeared to have been "endemic and pervasive" and it was "concerning" they may still have been "relevant" to Mr Stevens' death.

She said the trust was aware of the failings which "contributed to people not getting the right help at the right time".

A spokesperson for Tees, Esk and Wear Valleys NHS Foundation Trust said: "It is incredibly sad when a person that has been in contact with any of our services dies and our hearts go out to families who have lost loved ones.

"We would always carry out a review of our care so that we can understand if there are areas where we can improve.

"We are committed to providing safe, high quality services for people across the communities that we support.

"As you would expect we are unable to comment on the details of individuals in our care."

A date for the full inquest, which could last up to three days, is yet to be set.