A hospital’s decision not to recall a young patient with mental ill health played a part in his death, an inquest concluded.

Tom Creffield, described by his family as “beautiful, clever and imaginative”, died in his flat in Redcar on February 6, 2020.

At the time the 24-year-old, was on a short period of leave from Lustrum Vale mental health unit in Stockton, run by the trouble-hit Tees, Esk and Wear Valleys (TEWV) NHS Trust, where he was receiving treatment.

Read more: MP renews inquiry calls after health trust pleads guilty to deaths under care

An inquest jury concluded Tom did not intend to take his own life on the day of his death and that plans made by healthcare staff were “not in his best interests.”

But TEWV insists they reviewed Tom’s care in 2020 to ensure that best practice is followed. 

TEWV staff also failed to recall him to the hospital, even though his family raised serious concerns about his welfare.

Both of these factors were found to have contributed “more than minimally” to Tom’s self-inflicted death while his mum Claire said he was “let down badly at a time when he was desperately vulnerable.”

The Northern Echo: Tom CreffieldTom Creffield (Image: FAMILY)

TEWV’s chief nurse, Beverly Murphy, responded to the inquest’s conclusion, saying they reviewed Tom’s care in 2020, to “ensure we continue to learn and improve the care we provide.”

But the Creffield family’s lawyer, Gemma Vine, described Tom’s discharge as “at best haphazard and at worst shambolic.”

It comes during a period of increased scrutiny for TEWV; last week, the Trust pleaded guilty in connection with the deaths of two young women in their care, Christie Harnett and Patient X. They are set to go to trial for the death of a third patient, Emily Moore, early next year.

Tom had a long history of mental health struggles, being in and out of inpatient care since he was 18, most recently, for over two years. He had received a diagnosis of both paranoid schizophrenia and autism.

Speaking after the inquest his mother Claire Creffield said: “Senior members of Tom’s care team let him down badly at a time when he was desperately vulnerable.”

Tom had chronic issues with self-harm and suicidal thoughts which were still a concern at the time of his death – but his treatment team were working towards his discharge back into the community.

Three months before, in November 2019, his application to be placed in specialist autism-supported living in Durham was rejected, but Tom had managed to secure a private flat in Redcar.

He picked up his keys a month before his death, and a plan was established for graduated leave, but halfway through January, he came back onto the ward at Lustrum Vale having taken the recreational drug ketamine.

Still, Tom was granted a week of unescorted, overnight leave without assessment, in early February.

When a support worker visited, he was guarded and would not meet her eye, and there was the smell of amyl nitrate, the drug more commonly known as poppers.

In front of the jury, Tom’s psychiatrist noted he should have, at this point, been recalled to hospital.

The Northern Echo: Tees, Esk and Wear Valleys NHS Trust.Tees, Esk and Wear Valleys NHS Trust. (Image: The Northern Echo)

A day before his death, his care team met to discuss his needs and care plan – but the responsible clinician conceded that she had not read Tom’s notes before the meeting, nor was she aware of his symptoms.

His family also raised concerns about his welfare, saying he would be safer in supported accommodation – but a day later, he was found dead from self-inflicted injuries.

“The lessons learned from his death must not simply result in the introduction of yet more paperwork,” Tom’s mum Ms Creffield said.

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“There needs to be a genuine improvement in clinicians’ ability to hear their patients’ voices, to explore with patients what their needs are, and to meet those needs effectively.”

Tom’s brother Joe added: “Ultimately, I think the transition was too much for him and he felt overwhelmed by it.

“I prefer to remember him in early childhood, when we would play together without any cares and the enormity of life did not press down on him quite so relentlessly.”

Lucy McKay, spokesperson for INQUEST, said: “Tom was receiving care under a mental health Trust that has been widely criticised for its part in many other preventable deaths.

“He is yet another young man with autism and mental ill health who has been failed by the NHS.

“Urgent action must be taken locally and nationally to address the issues identified and ensure this Trust can provide safe care in future.”

Beverley Murphy, chief nurse at the Trust, said: “Our thoughts are with Tom’s family and friends during this incredibly difficult time.

“We completed a review of Tom’s care following his death in 2020, to ensure we continue to learn and improve the care we provide.”