AN inquest is underway into the death of a former jockey and equine dentist, who was found dead at his home just hours after a mental health crisis team said he was not an immediate suicide risk.

Dean Crossman died on June 18, 2019 at his home in Stockton.

The 51-year-old was well-known in the equestrian community in County Durham and across the North East.

The inquest at Teesside Magistrates' Court heard Mr Crossman had been visited by the mental health crisis team, run by Tees, Esk and Wear Valley NHS Foundation Trust, twice, as well as paramedics and police officers in the hours before his death.

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However, he was left alone from about 7am and was found hanging by two workers who visited him at home to carry out a mental health assessment later that morning.

Mr Crossman had made threats to take his life in the early hours, prompting a call to paramedics who attended his home address.

A mental health crisis team then attended at about 3am and put in place a plan aimed at keeping him safe – leaving him with a friend.

However, the safety plan “fell apart” when the friend left, the court heard.

Following the first assessment by the team, they asked Stockton Council’s emergency duty team to carry out an assessment under the Mental Health Act – which would allow them to detain him in hospital against his will.

However, this was not started and when the crisis team called the on-duty social worker, just after 6.30am, she was told Mr Crossman, who had refused hospital care, was no longer an immediate suicide risk.

The inquest heard about the difficulties in carrying out a Mental Health Act assessment during the night, with problems highlighted around getting an ambulance to transport people to hospital and in finding a second doctor, who is needed to approve an order under the law.

Evidence was heard from social worker Pauline Hancock, the approved mental health professional (AMHP) who was working on the night shift by herself at the time, and was also dealing with a safeguarding incident involving a child with a head injury, and manager of the emergency duty team Graham Lyons.

The inquest heard it is often difficult to find a second doctor after midnight, and particularly after 4am – though the situation has improved due to the introduction of an app to make it easier for AMHPs to contact available doctors.  

Mr Lyons also said the emergency duty team had problems with getting an ambulance to transfer patients if they were detained under the Mental Health Act.

At the time of the incident, private ambulance company ERS held the contract.

Mr Lyons said this had been reviewed by the clinical commissioning group (CCG) and it had been decided to find a new provider – however this had not happened as an alternative had not been found. Problems in the system still exist, Mr Lyons added.

Police Constable Victoria  Plumpton,who attended with a colleague at 6.18am, leaving when the crisis team attended for a second time, told the inquest Mr Crossman had denied having plans to take his life.

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She added officers would not have left him alone if a mental health team had not arrived. She said: “He seemed very low. His body language was quite defeated and he was definitely not in a good way.”

Inspector Ashley Harvey, of Cleveland Police, described the increased demand on the police due to mental health related incidents. 

The officer received a call about Mr Crossman at 5.13am, from the wife of his friend who had been with him. There were concerns he was alone, and had been writing suicidal notes.

There was then a conversation between police and the crisis team before officers were dispatched to check on his welfare.

Insp Harvey said: “I felt this was an example of another agency expecting police to deal with a matter with no explanation other than having limited staffing.

“My first conversation was to push back to the crisis team to manage the incident. We were in much the same position with staff. The decision to deploy officers went against this as our overriding concern was for Dean.”

Georgina Nolan, who is representing Mr Crossman’s family, submitted there were “gross failings” which had contributed to his death. She said there were failings on the part of the crisis team and there was a failure to do a Mental Health Act assessment or to seek advice from the consultant psychiatrist.

The inquest continues.  

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