Inquest: Willington man died as mental health trust was 'firefighting because of a lack of staff'

David Stevens took his own life at his home in June 2022. Credit: Family handout/ITV Tyne Tees

A man who took his own life made multiple calls to a mental health crisis team that was experiencing "a staffing crisis" with unqualified practitioners answering calls, an inquest as heard.

David Stevens, 57, from Willington, in County Durham, had anxiety and depression and took his own life at his home in June 2022.

The inquest in Crook on Tuesday 17 October heard that the day before Mr Stevens died he had been discharged from University Hospital North Durham after an overdose.

Mr Stevens was under the care of the Tees Esk and Wear Valleys NHS Trust and at the time of his death his care was being led by the trust's access team which deals with patients considered as low-risk of self harm and suicide.

The inquest heard in the months before his death Mr Stevens made multiple calls to the police, the Samaritans and the County Durham and Darlington Crisis team but the access team was not aware he had made these calls.

It also heard that at the time Mr Stevens was making these calls the crisis team was in special measures and had been experiencing a staffing crisis with unqualified practitioners taking calls.

Mr Stevens told the crisis team he had stopped taking medication and had asked for advice about what he should do. The coroner was told this information was not shared with his GP nor was a medication review carried out which is something the crisis team would have been able to authorise.

The inquest heard a serious incident investigation carried out by the trust following Mr Stevens' death found there was a lack of joined-up thinking, poor assessments carried out by inadequately trained staff in the crisis team and a robust safety culture was not visible.

Lynn Lewendon from the North East Clinical Commissioning Group who carried out the serious incident review told the inquest “there was a culture of firefighting at the trust because they didn’t have enough staff”.

The inquest also heard from Sharon Salvin, the Associate Director of Nursing at the Tees Esk and Wear Valleys NHS Trust who said the trust had learnt lessons following Mr Stevens' death.

She told the inquest the new leadership team came in at the end of May 2022 and it has made significant improvements. She said the County Durham and Darlington Crisis team came out of special measures in June 2023 and is now in a very different place. Mrs Salvin said the trust has 70-80% of qualified practitioners in place and are at a level the team can operate safely.

She also told the coroner the trust has employed advanced nurse practitioners into the crisis service since Mr Stevens' death and it has also introduced a new listening service for patients within the crisis team.

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