A trouble-hit mental health trust has been slammed after failing to file an incident report 13 months after it was due following the death of a patient.

The Tees, Esk and Wear Valleys (TEWV) NHS Foundation Trust patient died on July 10 last year after being discharged home following a mental health assessment.

The trust launched a serious incident investigation into the 32-year-old's death later that month, which under NHS guidelines should have been completed within 60 days.

However, the review remained unallocated with no timeframe for completion for over seven months, and has since been delayed several times. At the end of September, it was still incomplete.

Janine Richards, Assistant Coroner for Durham and Darlington, strongly criticised the trust saying: “If the final version report is received by the end of October it will be some 15 months since the patient's death and some 13 months outside the NHS framework.

“This is neither timely nor responsive.”

TEWV confirmed to this newspaper it has since completed its investigation.

The coroner expressed the concerns in a prevention of future deaths report.

She went on to say action should be taken as delayed investigations could “permit lethal hazard to persist” and restrict their value in preventing avoidable deaths.

Bur Beverley Murphy, chief nurse at the trust, said: “HM Coroner has received all information requested from our trust for this serious incident.

“Our recovery plan for serious incident reviews has resulted in significant improvements and we continue to share our progress with HM Coroner and our regulators.

“We do not underestimate the effect a delay may have on those who have lost loved ones and we have apologised to the families affected by this.

“We are committed to completing serious incident reviews in a timely way. We work with families to answer their questions and provide support during what is an incredibly difficult time.”

It is the third such report about delays in investigations into serious incidents at TEWV.

Senior Coroner Jeremy Chipperfield previously said delays in death investigations are “routine” at the trust.

He wrote: “TEWV serious incident death investigations, at all levels of seriousness, are routinely (if not invariably) significantly delayed.”

A report into the death of patient Ian Darwin, who died from multiple injuries in Durham in March of this year, was also delayed.

National guidelines about serious incidents state that they should be reported “without delay” and within “two working days of the incident being identified”, and an investigation report finalised within 60 days of the incident first being reported.

An inquest into the patient's death is due to be heard this month.

It comes amid a period of intense scrutiny for the trust.

In September the trust pleaded guilty in connection with the deaths of two young women, Christie Harnett and Patient X. TEWV pleaded not guilty and will go on trial in connection with the death of a third patient, 18-year-old Emily Moore, next year.

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Last month an inquest into the death of 24-year-old Redcar man Tom Creffield found lapses in the trust’s care led to his self-inflicted death in early 2020.

Another inquest at Crook Coroners Court heard that 57-year-old David Stevens called TEWV’s crisis team 37 times in the months before he died but concerns about his mental health were not escalated by staff, and there were a “multiplicity of issues” with his car.

Last week The Northern Echo reported how 20 crisis team patients died in the 12 months since Mr Stevens death in June 2022 when TEWV claimed it had made “significant improvements” to the service.

This summer, The Northern Echo revealed that 41 mental health patients died unexpectedly – which may mean by suicide or by an unexpected physical health issue, drug and alcohol-related, or accidentally - between February 2021 and June 2023, within six months of contacting the crisis team.

The new information has revealed that nearly half of these unexpected deaths – 20 – occurred in the 12 months between June 2022 and June 2023, following Mr Stevens’ death, leading to the accusations that lessons have not been heard.