The jury at an inquest into the unexpected death of a Darlington man has retired to consider their conclusions. 

Matthew Gale, 37, died on the train tracks in March last year after failing to return to the mental health hospital he was sectioned at. 

As Matthew died whilst under state care - he was detained for his own safety at West Park Hospital in Darlington under the Mental Health Act - 11 jurors have been called in to make decisions on the case. 

Over the last two days, the court has heard that there was a "Swiss cheese effect" with Matthew's care, where errors built up. The wrong form was filled out granting Matthew's leave, the staff never told Matthew's mother Sue Gale that she should always accompany him on leave, and the hospital did not notice he had failed to return for an hour and forty minutes. 

Much of the inquest had focussed on Matthew's leave, after Sue told the court that she was "absolutely not told" of any conditions attached to his leave. 

Earlier in the week, witness for the hospital trust, nursing quality director Alison McIntyre, said that she “could not say” whether alerting the police at 5.30pm would have saved Matthew’s life, but said it was a “missed opportunity”.

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The jury will answer who Matthew was, when and where he died, and how he came about his death. As part of this, they will be considering if failures in Matthew’s care amounted to neglect, and if this contributed to his death.

In this context, neglect constitutes "a gross failure to provide basic medical attention to someone in a dependent position". 

Assistant coroner for County Durham and Darlington Simon Connolly told the jury that this could be "a failure to impart information."