A beloved son was found dead on railway tracks on Mother's day after staff at the mental health hospital where he was detained failed to notice he had not returned, an inquest heard.

Matthew Gale, 37, from Darlington, died  on March 19, 2023. In the month before his death, Matthew had been sectioned under the Mental Health Act.

Today (Tuesday, May 21) an inquest jury at Crook Coroners’ Court heard that there were “many errors in care” in the run-up to Matthew’s death, including incorrect forms filled out, a severely delayed meeting, and a lack of communication with Matthew’s family.

Staff from West Park Hospital, in Darlington, run by Tees, Esk and Wear Valleys NHS Trust (TEWV), admitted to the court that there had been a “Swiss cheese effect” with Matthew’s care, where multiple weaknesses lined up, resulting in his care falling apart.

The 37-year-old, a beloved son to Sue Gale and twin brother to James Gale, had been receiving treatment at West Park Hospital in Darlington, for ill mental health. He was diagnosed with schizoaffective disorder, after exhibiting paranoid beliefs and behaviours.

As Matthew was an inpatient at West Park detained under the Mental Health Act, leave to see family, go into the Darlington area, or even to walk around the hospital grounds, had to be approved by his clinician. This is known as Section 17 leave.  

At the time of his death, Matthew was approved to have four hours off the ward a day, either escorted by a member of staff, or accompanied by a trusted loved one.

The court heard that his suicide risk was noted in his medical file – only days before he was admitted to hospital, he had been seen trying to take a taxi to a nearby train station.

But Dr Ibrahim Jawad, Matthew’s consultant psychiatrist in the hospital, filled out the wrong form, using an outdated document that was missing a section about the need to discuss leave arrangements with family, and obtain a signature from whoever was accompanying Matthew out of hospital.

Dr Jawad said: “That [the wrong form] should have been flagged with me by the Mental Health Act office. [The right form] would have served as a prompt for Matthew’s mother to be contacted.”

About patchy record keeping, the doctor said: “Going through his notes, I did not find too much documentable about how leave had gone.

In questioning, the barrister representing the Trust, Gina Wells, said: “The Trust accepts communication could’ve been better with Matthew’s mother.”

When he died, Matthew was on leave from the hospital, and was expected back on the ward shortly before 5pm.

But the hospital only found out that he had gone awol when Matthew’s mother phoned them at 6.40pm. Sadly, the British Transport Police had already logged the incident that killed Matthew. He died at 5.53pm.

Trust witness Alison McIntyre, associate director of nursing quality at TEWV, said that Matthew’s absence should have been picked up on a nurse round, scheduled to happen between 5pm and 5.30pm.

She said she “could not say” whether alerting the police at 5.30pm would have saved Matthew’s life, but said it was a “missed opportunity”.

Mrs McIntyre admitted that the trust would “have to take the understanding that if something was not recorded, it did not happen.”

She added that though the Trust were not trying to “make excuses”, she said a mixture of “busyness, human error, and high acuity on the ward” contributed to errors made.

Whilst questioning the witness, Simon Connolly, assistant coroner for Durham and Darlington, said: “I don’t want to be critical, but one of the issues I was struck by was the trust's own requirements. 

“I don’t understand how this situation was allowed to happen."

Mrs McIntyre responded: “I think there was an assumption that there was a running conversation with the family.”

Dr Jawad, who left his job at TEWV last month, said he “can’t explain” why a formulation meeting, which should happen within 72 hours of a patient being admitted to hospital, occurred eight days into Matthew’s stay.

The inquest continues.

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