Only half of a crisis team's positions were filled when a man died after contacting them 37 times for mental health help, it has emerged.

David Stevens, 57, was a patient of County Durham and Darlington Crisis Team (CDDCT), 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, after he repeatedly contacted TEWV services with concerns about anxiety, issues sleeping, hearing voices, and depression.

There were unqualified and unregistered practitioners answering calls, including from Mr Stevens, on the team designed to deal with vulnerable patients in the throes of a mental health crisis, an inquest in Crook heard today (Tuesday, October 17).

TEWV were aware of issues with their crisis service that may have contributed to Mr Stevens’ care, which was deemed to be “not at expected levels”.

The Northern Echo: David Stevens died on June 15, 2022.

Mr Stevens’ sister, Keeley Card, called his death “needless and untimely”, saying that the family feels as though he was “let down massively” by his mental health team.

There were “longstanding issues” with the CDDCT that TEWV was aware of in the months preceding Mr Stevens’ death. A thematic review had been commissioned after four people died in quick succession in early 2021.

Still, these issues, such as poor staffing levels and unregistered and unqualified practitioners, may have played a factor in the care that Mr Stevens, which was given months later.

“Nearly every instance” of contact Mr Stevens had with the crisis team was “not at the expected level of care” according to Lynn Lewendon, who conducted a serious incident review into his care. However, it was also noted that Mr Stevens had found many interactions with TEWV’s staff “helpful”.

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Mr Stevens had called the CDDCT asking for cognitive behavioural therapy, and requesting advice on his medication – which should have been passed onto his GP, but was not.

Ms Lewendon said that she found a “culture of firefighting” at the crisis team due to low staff levels.

The crisis team had been in business continuity measures – where only 50 per cent or fewer positions were filled, and the aim was to keep the essential services going - for the months leading up to David’s death.

The “staffing crisis” meant that unqualified and unregistered practitioners had to pick up crisis calls from vulnerable patients – often meaning that triage tools were underutilised or records incomplete.

Though improvements have been made by the CDDCT, about 20 to 30 per cent of positions on the team are currently unfilled, said the team’s director of nursing Sharon Salvin.

Mr Stevens died at his home after being released from hospital just a day before after a failed attempt to take his own life.

TEWV was accused of “silo working” and “not taking a helicopter view” of Mr Stevens’ case, with clinicians on different teams not communicating with each other, police, A&E staff, or GPs.

Ms Lewendon said: “No one was able to take a helicopter view (an overview) about his calls to teams – to me, frequent calls to multiple teams would indicate he’s increasingly anxious”,

But the trust has said that they are “committed to learning”, with Mr Stevens' case now being used as a training example to warn staff about the “dangers” of silo working.

There have been changes in structure, leadership, and procedures in the CDDCT since Mr Stevens' death, and the service has come out of business continuity measures, according to Ms Salvin.

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

This inquest comes in a period of intense scrutiny for TEWV. Only last month, the trust pleaded guilty in connection to the deaths of two of their patients, Christie Harnett and Patient X. On the same day, the trust pleaded 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.

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, or visit 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.