The family of a Darlington man who was neglected by hospital staff before he took his own life on the train tracks have expressed their worry that more deaths could happen unless changes are made.

Matthew Gale, 37, died on the train tracks on Mother’s Day last year. At the time, he was an inpatient at West Park Hospital sectioned under the Mental Health Act.

This week, an inquest jury at Crook Coroners' Court unanimously found that neglect by hospital staff had contributed to his death, after the wrong forms were completed, and Matthew's mother, Sue, was not told that she must stay with him at all times whilst he was on leave. 

Whilst on a period of leave with his mother, Sue Gale, Matthew was able to take himself to a train station, where he tragically died. 

Now, Matthew's mother and twin brother James Gale, have told The Northern Echo that they do not believe that West Park Hospital "have learned from Matthew's death".

Sue, a retired nurse, said: "As a family, we always knew that West Park failed. Just common sense would tell you that. So, on that balance, I am pleased with the verdict, but it's never going to bring back my son.

"It needn't have happened. It's another needless death on the hands of the trust."

James, a firefighter, added: "The verdict confirmed the fact that there had been failures and neglect in Matthew's care. If their policies and procedures were followed, he wouldn't have committed suicide.

"The trust never formally apologised. They've never so had the humanity to approach the family and go, 'Look, we're sorry, that Matthew Gale committed suicide in our care.'

"So the first admission of any condolence was today, on the witness stand, nearly 14 months later."

Sue added: "The manner of his death, and the catastrophic failure of West Park to keep a vulnerable young man safe, as is their duty under the Mental Health Act, has made life unbearable. Given the right help and timely medication, my dear son would be alive today.

"We have always known Matthew was let down by West Park, and the jury has confirmed their gross failure to adhere to policy and law to protect his life."

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

Alison McIntyre, associate director of nursing quality at Tees, Esk and Wear Valleys Trust (TEWV), which runs West Park Hospital, told the court that improvements had been made based on Matthew's case. 

She said new systems are in place to ensure the right forms are always filled out and checked, and staff have been educated on new policies, providing guidance on what to tell families before they take sectioned patients on leave. 

A new bespoke electronic records system, CITO, has been put in place, in line with NHS plans to strengthen patient care. 

Assistant coroner for County Durham and Darlington Simon Connolly agreed that the systems in place now are more robust than when Matthew was failed 14 months ago. 

But the family raised concerns that the policy still does not make it an obligation for forms to be signed by family members before patient outings. 

James said: "It absolutely could happen again, because they haven't implemented that you physically sign a piece of paper before taking someone out."

"The fact is that they still haven't learned the lessons that they have to have a signature to know that the person taking a patient out of the hospital knows their responsibilities. 

"They're implementing a new IT system, but let's be honest, IT systems, particularly in the NHS, fail. They could just have a very simple process to sign someone out - but they haven't done that."

The family joined calls for a public inquiry into the trust, where an independent judge would look into the string of tragic deaths and missed opportunities at Tees, Esk and Wear Valleys trust. 

James said: "It should be taken to a public inquiry now, before we have the same situation in six months, when unfortunately someone else commits suicide or has a bad care experience within that trust, which will happen in its current state."

Sue added: "Maybe [we've not had an inquiry yet] because we're in the North East of England. Maybe if we were in a more affluent place a public inquiry would have happened. But because there's a north-south divide, maybe the government people aren't interested.

"Family is the most important thing, and for that to be destroyed, it's devastating."

The family thanked their legal team, and the jury, and paid tribute to Matthew, who they describe as "kind, fun-loving, full of empathy, handsome and hard-working."

Beverley Murphy, chief nurse, said: “Our thoughts this week have been with Matthew’s family and friends. We are so sorry for their loss.

“We reviewed Matthew’s care and treatment following his sad death. As we shared with the coroner, we immediately strengthened our processes on how we share information about leave with families.

“We have acted on the inquest findings and continue to improve so that we can provide the best care possible.”

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