A clinician treating a man for his mental health struggles had no idea he’d called a crisis team within the same NHS trust 37 times in the months before his death.

David Stevens was a patient of Durham and Darlington Crisis Team (DDCT), part of the Tees, Esk and Wear Valleys (TEWV) NHS Trust when he took his own life at his home in Willington, on June 15, 2022. 

He had been discharged from hospital a day earlier after a failed attempt to end his life.

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But the clinician due to lead his care did not know about his calls to the crisis team, the Samaritans, police, or David presenting at A&E.

He also only had one face-to-face appointment with her on May 23, 2022, between being referred to the service by ‘Talking Changes’ on January 25, and his death on June 15 of the same year.

An inquest at Crook Coroners Court heard David had been discharged from University Hospital North Durham after an overdose and returned to his home in Willington where he had closed the curtains.

The Northern Echo: David Stevens.David Stevens. (Image: FAMILY)

A neighbour, who David was friends with, had attempted to contact him but received no response and called police. Officer PC Howie who attended the scene attempted to call for David but called back-up to force entry when he received no response.

He was found on the floor in his bedroom and paramedics declared him dead shortly after 1pm on June 15.

A pathologist concluded David, formerly a taxi driver, died due to hanging. He had no alcohol in his system and drugs present were consistent with therapeutic levels. He was on a range of medication prior to his death.

Read more: 41 patients died in six months following contact with TEWV crisis team

Giving evidence on Monday (October 16) morning Kay Markwell, an access clinician with the at Tees, Esk and Wear Valleys NHS Trust, said she had no knowledge of David showing at A&E, or calling TEWV’s own crisis team, despite providing his care.

Miss Lily Lewis, lawyer for the family said: “You said you weren’t aware of the calls that David was making to the crisis team and weren’t aware of contact that David made with the police where he raised thoughts of suicide.”

Ms Markwell replied: “Having all of that background completely changes things.”

“David had responded very well to my appointment on May 23,” she added

She added that it was not “routine” to check medical patients’ GP medical records after lawyers for the family listed David history which revealed he was feeling “in a bad way” and had again expressed suicidal thoughts.

The Northern Echo: An inquest being held at Crook Coroners Court is expected to last three days.An inquest being held at Crook Coroners Court is expected to last three days. (Image: NORTHERN ECHO)

The inquest heard he had expressed remorse and regret about his overdose during an assessment prior to his hospital discharge.

Ellen Clark, who assessed Mr Stevens on June 14, told the court: “I didn’t think that he was going to leave the department and put himself in any imminent risk.

Information from an emergency department after a previous attempt to end his life by hanging had not been seen prior to this assessment, the court heard.

Miss Lewis said: “Although you spent quite a long time with David discussing the risk of overdose, you did not have any safety plan about the risk of hanging.”

Ms Clarke responded: “I wasn’t aware of any risk of hanging. It looks like information has not been transferred from the emergency department system onto our system.”

She added it would have been factored into a safety plan if it was known about.

He was due to have an appointment with Ms Markwell six days after his death on June 21.

Assistant Coroner for Durham and Darlington Ms Janine Richards said the scope of the inquest would be to look at David’s mental health diagnosis and treatment, and whether there were any failings or missed opportunities implicated.

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The inquest in Crook, which is expected to last three days, continues.

It comes in a period of intense scrutiny for TEWV. Only last month, the trust pled guilty in connection to the deaths of two of their patients, Christie Harnett and Patient X. On the same day, the trust pled not guilty concerning the death of Emily Moore, 18, who died at a TEWV hospital in Durham. Emily’s case is set to go to trial in February next year.

This summer The Northern Echo revealed that 41 mental health patients died within six months of getting care from the Durham and Darlington Crisis Team (DDCT) - since February 2021.

The TEWV-run service is intended to offer urgent support and care to adults in County Durham and Darlington who are experiencing a mental health crisis.

A Care Review Report into David’s death was completed by TEWV on December 8, 2022. The Report identified that the Crisis Team was operating under business continuity contingency measures due to low staffing, resulting in inexperienced staff and inadequate training for staff supporting patients who called the Crisis Team.

Sharon Banbrough, who was seconded to the crisis team in June 2022 when she answered a call from David, told the court of  "limited staff" and "lots of issues" at the time.

She added: "We should have had maybe four qualified clinicians [...] often there were two or three.

"It was very very low staff".

If you are in need of support you can contact the following:

- Samaritans is available, day or night, 365 days of the year. You can call them for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch.

- If U Care Share on 0191 387 5661 or text IUCS to 85258

- SANE on 07984 967 708, Calm on 0800 58 58 58

- Tees, Esk and Wear Valleys NHS Foundation Trust crisis line 0800 0516 171.