Leighton Hospital mental health team 'failed' Moulton dad-of-five

Gary Darlington was found in the garden shed of the family's home on Barlow Road by his fiancée’s mum, at around 7pm on Friday, July 14, 2023.

He’d slept the previous night in the shed, which his fiancée said was his ‘safe place’, and had nailed a plank of wood across the door from the inside.

The 37-year-old struggled with his mental health since he was 21, and was being treated by his GP for severe anxiety and depression.

He was also having counselling from Survive, a charity which supports victims of abuse, and had been on antipsychotics in the past.

At an inquest at Cheshire Coroners’ Court on Friday, April 19, senior coroner, Jacqueline Devonish, heard how on April 11, 2023, Gary and his fiancée called his GP after he started hearing voices.

Gary asked for antipsychotic drugs, which had worked for him in the past, but the GP said only a psychiatrist could prescribe them.

Gary Darlington had been working with mental health services since he was 21 (Image: Supplied)

She made a referral the same day to the Community Mental Health Team (CMHT) at Leighton Hospital, asking for a psychiatrist to urgently review his medication.

This was picked up by a mental health nurse the following day, who looked at his medical records, which included details of long-standing suicide ideation, as well as a previous overdose, and judged the risk of him harming himself to be low.  

She asked for the medication review, but nothing had been done with the request by the time Gary committed suicide three months later.

In fact, it was September, two months after Gary died, when the request for a medication review was finally seen by a psychiatrist. 

The court heard from 13 witnesses, including the head of clinical services at Cheshire and Wirral NHS Foundation Trust, Mark Brunnell.

Mr Bunnell told the court the Community Mental Health Team (CMHT) at Leighton Hospital was designed to run with one full-time psychiatrist, but for at least half the time Gary was waiting for his medication review, they simply didn’t have one. 

This is despite them being sent between 50 and 100 psychiatric referrals every day.

At one point, a locum psychiatrist had been taken on but soon left, meaning referrals like Gary’s were only being dealt with when a psychiatrist could be ‘borrowed’ from another team.

But Mr Bunnell added other teams were also short of psychiatrists, so this was rare.   

Since Gary’s death, he said, CMHT have made changes to the way it operates, including recruiting a permanent, full-time consultant psychiatrist, as well as a part-time locum.

It has also reviewed how it communicates with patients and their families, and now informs them when their request can’t be dealt with in four to six weeks.

After hearing all the evidence, Mrs Devonish recorded a conclusion of suicide.

She added: “This was contributed to by the absence of protocols for review of referral waiting lists following urgent GP referral for psychiatric review.

“It was also contributed to by resourcing issues when there was no psychiatrist available to review them urgently.

“It was also contributed to by no communication from mental health services with Mr Darlington or his family following confirmation that a referral would be made.

“I fully accept he was failed by the mental health service.

“This is a very sad case, and I’m truly sorry he didn’t get the help and care he needed, and indeed, had asked for.”

Samaritans is available round the clock, every single day of the year, providing a safe place to talk for anyone who is struggling to cope.

Call 116 123 (this number is free to call and will not appear on your phone bill), 01204 521200 or email jo@samaritans.org.