A Darlington hospital trust has been criticised for "inconsistent" records after it was found it neglected a Darlington man before his death.

Matthew Gale, 37, died on the train tracks on Mother’s Day last year. At the time, he was an inpatient at West Park Hospital sectioned under the Mental Health Act, being treated for schizoaffective disorder.

Before his death, hospital staff filled out the wrong forms, failed to tell Matthew’s mother, Sue Gale, that she must stay with him at all times when he was on leave, and did not notice he was missing for nearly two hours on the day that he died.

At an inquest into Matthew's death, the jury unanimously concluded that Tees, Esk and Wear Valleys (TEWV) mental health trust had neglected him, which contributed to his death. 

Matthew (L) and his twin brother James (Image: Family)

Now, a coroner has said that communication issues at the hospital persist - and has told the trust they must take action to prevent any future deaths. 

A spokesperson from the trust said they "continue working hard" to improve the safety of inpatients taking hospital leave.

In a report sent to TEWV, assistant coroner for Durham and Darlington, Simon Connolly, said: "The Trust acknowledged and admitted that there was no evidence in any records that discussions had been had with Matthew’s mother [about Matthew's leave conditions] or that a copy of the leave form had been provided to her.

"At inquest, The Trust gave evidence of changes implemented since Matthew’s tragic death to avoid future recurrence and I requested additional evidence in relation to audited compliance data."

But Mr Connelly added that when this data was sent through, it was "inconsistent generally"  -  specifically relating to providing forms to people accompanying a patient on leave.

Data from TEWV showed that only 50 per cent of these leave forms were shown to carers in December 2023. There was a 52 per cent compliance rate in March 2024 and a 76 per cent compliance rate in May 2024. 

A compliance rate of 80 per cent or above is considered to be “good”. 

The coroner also raised concerns that new changes to leave forms - because of the rollout of a new digital system CITO - removed the need for forms to be signed off by the person accompanying the patient out of the hospital. 

The coroner said that this "gives rise to a concern that there is a risk that future deaths could occur ... unless action is taken".

Matthew's family have been left heartbroken by the loss of their "kind, fun-loving, full of empathy" son and brother. 

Matthew's mother, Sue, a retired nurse, said: "As a family, we always knew that West Park failed. Just common sense would tell you that. 

"The manner of his death, and the catastrophic failure of West Park to keep a vulnerable young man safe, as is their duty under the Mental Health Act, has made life unbearable."

Twin brother James Gale, a firefighter, added: "If the Trust's policies and procedures were followed, he wouldn't have committed suicide.

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"It absolutely could happen again, because they haven't implemented that you physically sign a piece of paper before taking someone out."

Dawn Jessop, Deputy Chief Nurse at Tees, Esk and Wear Valleys NHS Foundation Trust said: “Our thoughts remain with the family and friends of Matthew throughout this difficult time. 

“We have taken steps to improve communications with families and involve carers during leave and will continue working hard to improve the safety of those taking leave from our hospitals.”

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