A CORONER has said she is concerned there will be further deaths if changes are not made to the process around getting assessments under the Mental Health Act.

Jo Wharton, the assistant coroner for Teesside, is writing to the NHS over concerns raised following the death of a former jockey and equine dentist.

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

An inquest into the death of the 51-year-old, which is being held at Teesside Magistrates’ Court, concluded he died by suicide.

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Ms Wharton said she did not find there had been neglect in Mr Crossman’s case.

But she did say she would write the Tees Valley Clinical Commissioning Group (CCG) and NHS England over concerns raised by the Emergency Duty Team (EDT), which is responsible for carrying out assessments under the Mental Health Act.

Yesterday, team manager Graham Lyons told the inquest the EDT faced difficulties in getting a second doctor to carry out assessments, as required by law, and in getting a timely response from the private ambulance ERS, which has a contract to transfer patients to hospital.

Ms Wharton was told the EDT team had concerns is issues could lead to delays in patients being assessed. 

Ms Wharton said: “There is a risk future deaths will occur as a result. I will be making a report to raise two issues of concern. Mr Lyons gave evidence that he thought they were not just regional but that it’s a national issue.”

She added: “I do hope Dean’s family finds some comfort in the fact some action is being taken to prevent future deaths.”

A request for an assessment under the Mental Health Act had been made by a crisis team when it visited Mr Crossman's home in the early hours of the morning of his death.

The crisis team from Tees, Esk and Wear Valleys (TEWV) NHS Foundation Trust was called twice on that day. 

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On the first occasion, the team was called by paramedics who had attended the address after being called because Mr Crossman was making threats to take his life.

They spent about an hour and a half Mr Crossman and asked for a Mental Health Act assessment because he had refused hospital admission and was deemed to be at immediate risk of suicide.

However, the EMT Approved Mental Health Practitioner (AMHP), who was working alone on a busy shift, did not start the assessment.

When the crisis team attended for a second time at 6.30am, it was thought Mr Crossman was no longer at immediate risk and the request for an assessment was stood down.

Mr Crossman was left alone to sleep and have a shower before a mental health team was scheduled to visit him at 9.30am.

However, when two workers came to his home that morning, he was found dead. 

Following the death, a serious incident investigation took place and policies were put in place, including an escalation procedure.

Questions were asked about issues including why a consultant psychiatrist was not called and why steps had not been taken to remove a noose from Mr Crossman's home. It was later removed by police officers who asked his permission to take it away. 

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