The mother of a Darlington man who died after his hospital ward failed to notice that he was missing has said she was “absolutely not told” about any conditions to his leave.

Matthew Gale was sectioned under the Mental Health Act at West Park Hospital in Darlington, run by Tees, Esk, and Wear Valleys Trust (TEWV) when he died on the railway tracks in March 2023.

As he was detained for his safety, leaving the ward, even to walk in the hospital grounds, had to be approved by Matthew’s consultant psychiatrist.

The conditions of this leave stipulated that Matthew either had to be escorted by a member of staff, or accompanied by a loved one.

But Matthew’s mother, Sue Gale, today told the inquest into his death that none of this information had been communicated to her, even though she picked Matthew up from, that staff had never had conversations with her about leaving, and that she had not been shown the necessary form to sign.

The Northern Echo: Matthew Gale, right, with his twin brother James.

On March 19 last year, the day he died, Matthew failed to return to the hospital after a period of leave from West Park Hospital. He had been for a Sunday dinner with Sue to celebrate Mother’s Day.

Despite leave conditions stating he had to be accompanied at all times, Sue was unaware of this, and when requested he was dropped at his Darlington flat as he had housekeeping to do, she did not think twice about it.

When asked if she had been told about the conditions of Matthew’s leave, Mrs Gale said: “Absolutely not. Do you think as a mother if someone had explained that he was at a high suicide risk that I would have let him out of my sight?”

But Sue realised something was wrong when she was driving back over to pick him up again – saying: “It was a feeling I’d never felt before, I knew he had gone to take his own life.”

At 6pm, when she discovered he was no longer at his flat, she alerted the police of her worries, and later,  at 6.40pm, phoned staff on the ward.

Alison McIntyre, associate director of nursing quality at TEWV, said that Matthew’s absence should have been picked up on a nurse round, scheduled to happen between 5pm and 5.30pm.

But in a statement read to the court, nurse Danielle Dolan, the nursing lead on Matthew’s ward, said the staff had not realised Matthew was missing until Mrs Gale phoned the ward. She quickly contacted the police, raising her concerns.

Sadly, the British Transport Police had already logged the incident that killed Matthew. He died at 5.53pm.

The barrister for the trust, Gina Wells, said: “The Trust accepts communication could’ve been better with Matthew’s mother.”

The court heard that this contravened TEWV’s own policy, and good practice guidelines on family involvement in Section 17 leave for patient safety.

Yesterday (Tuesday, May 21), at Crook Coroner’s Court, it emerged that Matthew’s consultant psychiatrist, Dr Ibrahim Jawad, filled out an outdated form when granting Matthew his leave, and that medical records lacked note of any conversations had with Matthew’s family about leave.

A meeting about Matthew’s care plan, which should’ve taken place in the first 72 hours of his hospitalisation, took eight days.

Mrs McIntyre said there had been a “Swiss cheese effect”, where multiple failures meant his care had fallen apart.

She added that she “could not say” whether alerting the police at 5.30pm would have saved Matthew’s life, but said it was a “missed opportunity”.

Tomorrow, jury deliberations are expected to start. Amongst other things, they will be considering if failures in Matthew’s care amounted to neglect and if this contributed to his death.

The inquest continues.

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