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The family of a County Durham man who took his own life say he would still be here had his calls for help been listened to.
Father of three David Stevens, 57, was under the care of the Tees Esk Wear Valleys NHS Trust when he took his own life at his home in Willington in June 2022.
He had a history of anxiety and depression and the day before he died, he had been discharged from University Hospital North Durham after an overdose.
A coroner has found there were missed opportunities to help Mr Stevens but she couldn't say if his death was preventable.
Mr Stevens was under the care of the trust's access team which deals with patients considered low-risk of self-harm and suicide.
The inquest into his death at the Crook Coroner's Court on 18 October was told the County Durham and Darlington crisis team were in special measures at the time.
They were described as having a "staffing crisis", with not enough staff and unqualified practitioners answering calls. The coroner was told this had led to a culture of "firefighting."
In the three weeks before he died, the inquest heard the access team were aware Mr Stevens had made 15 calls to the trust's crisis team - a service for patients having a mental health care emergency.
Mr Stevens told the crisis team he'd stopped his medication but this was not shared with his GP nor was a medication review carried out - something the crisis team could have authorised.
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.
Returning a conclusion of suicide, coroner Janine Richards said "better communication may have led to a robust assessment but I do not know what the outcome would have been or if it would have resulted in more intensive and appropriate treatment."
She added: "Given escalating risk, there seems to have been missed opportunities to reassess and manage David's risk but I don't know whether it would have prevented his death."
Ms Richards said she felt reassured the trust had made improvements following Mr Stevens' death.
A statement was read to the court from Mr Stevens' sister Keely Card. She said her brother was "massively let down by the mental health team" and it was "very distressing that he was not listened to when he sought help".
She added his "needless and untimely death could have been avoided."
The inquest also heard a thematic review into concerns around the Durham and Darlington crisis team had been carried out in November 2021 - seven months before Mr Stevens' death.
The inquest heard it had been prompted because four patients who had had contact with the crisis team died in a short period of time.
Sharon Salvin, the associate director of nursing at the Tees Esk and Wear Valleys NHS Trust, told the coroner 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 and that the trust has 70-80 percent 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 has also introduced a new listening service for patients within the crisis team.
Beverley Murphy, chief nurse at the Tees, Esk and Wear Valleys NHS Trust, added: “Our thoughts are with David’s family during this time and we remain deeply sorry for their loss. We understand that the inquest may have been very difficult for them.
“Throughout the hearing, our staff were open and transparent about the changes we needed to make and we are grateful for their professionalism.
"We are pleased that the improvements we have made were recognised by HM Coroner.
“We remain committed to these improvements to ensure we provide the best care possible.”
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