The devastated family of a man who died by suicide after calling a mental health trust for help have told of their frustration at the trust "getting off with a slap on the wrist". 

David Stevens, 57, called the County Durham and Darlington Crisis Team (CDDCT), a service run by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV), 37 times in the months before he died - but concerns about his mental health were not escalated by staff.

Though there were "a multiplicity of issues" with the care that David received, assistant coroner Janine Richards concluded that they had not caused his self-inflicted death at his Willington home in June 2022. She recorded a verdict of suicide. 

David's family were "shocked" by the conclusion, saying that "TEWV has got away with a slap on the wrist" for care they deemed "diabolical". 

They have called for a public inquiry into TEWV, fearing that "this could happen again". 

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The Northern Echo: David Stevens died on June 15, 2022.

A family statement, read by David's brother Kevin Stevens, said: "We, as a family, feel David was let down by the mental health team, despite numerous cries for help, which went unheeded and resulted in David taking his own life. 

"During the inquest, we have heard of systemic failures; in the way records were kept; failure to notify other departments and a lack of staff training, which we found very disturbing. 

"This is just one case: how many more cases have happened and how many more need to come to light for action to be taken?"

The coroner said that the team had "missed opportunities" to help David. At the time of his death, on June 15, 2022, David had been waiting for 21 weeks to start treatment for anxiety. His appointment was due to be on June 21. 

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A serious incident report, conducted by Lynn Lewendon, found that "a lack of communication and silo working led to a fractured picture of his needs and the level of anxiety that he was experiencing."

Ms Richards said that many of the clinicians who came into contact with David did not see the "longitudinal view", which included eight calls to the access team, 15 calls to the crisis team, two calls to the police and three trips to A&E, often acknowledging his suicidal ideation. 

She added: "Each of David's contacts was seen in isolation; no one saw the full picture of David's many contacts with many agencies."

Ms Richards also acknowledged that the Trust had made improvements - including changes in management and procedures - since David's death.

At the time of David's mental health crisis, CDDCT, a service operated by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV), was being operated in business continuity measures, with fewer than half of staff positions filled. 

A thematic review of the service, conducted seven months before David died, found "longstanding issues" with the CDDCT, such as poor staffing levels, and unqualified and unregistered practitioners answering calls from people in crisis.

Kevin added: "This week, we've heard of systematic failures. So much has come out that we did not know about. We weren't aware that he had called for help so many times. 

"We need a public inquiry into these deaths to stop something like this from happening again. What goes on has to be brought into the public domain.

"We're going to keep fighting for him - he won't be forgotten."

His brother-in-law, Maurice Card, added: "It's been diabolical - I am sure that if David had gotten to [his appointment with the mental health team] on June 21, he'd still be here with us today."

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Beverley Murphy, chief nurse at the trust, said: “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.”