2 October 2023

Before HM Senior Coroner Clare Bailey
Teesside Coroner’s Court
25 September –29 September 2023

An inquest has found a Tees, Esk and Wear Valleys NHS Trust mental health unit’s discharge planning, alongside a decision not to recall a young autistic man with mental ill health, contributed to his death. 

Tom Creffield was 24 years old when he died on 6 February 2020 at his flat in Redcar, Teeside. At the time he was on a short period of leave from Lustrum Vale mental health unit in Stockton-On-Tees, run by TEWV, where he was receiving treatment. 

Tees, Esk and Wear Valleys NHS Trust has been criticised for a high number of patient deaths, with research uncovering hundreds of deaths between April 2017 and March 2020.

In their evidence to the inquest, Tom’s family described him as beautiful, imaginative, and clever. Tom had diagnoses of paranoid schizophrenia and autism. He been in and out of inpatient care since he was 18, most recently for over two years. 

At the time of his death Tom’s treating team were working towards discharge back into the community. Tom had a long history of self-harm and suicidal thoughts. These remained chronic symptoms of his presentation, which were still a concern at the time of his death.

In April 2019 formal discharge planning began, including consideration of the accommodation to which Tom should be discharged. Between April and August 2019, the Trust pursued discharge to live alone in a privately rented flat with a support package. 

Tom’s treating professionals gave evidence at the inquest that this was because this was Tom’s preference rather than the result of a clinical decision. Tom had never lived on his own before.

On 19 August 2019, the Trust’s approach changed. It identified that it would be in Tom’s best interest to be discharged to supported accommodation. It found a suitable placement which catered for autism and instructed the Care Coordinator to submit an application. While this application was being considered, no steps were taken to identify possible alternatives. 

At the end of November 2019, the application for this placement was rejected. Tom was disappointed but confirmed he would be happy to look at supported accommodation in Durham (where he was more likely to get a place) or to be discharged to an independent rented flat. 

An email was sent from the ward requesting that alternative supported accommodation be found, but this was not pursued. With support, Tom found an independent privately rented flat in Redcar.

Tom was given the keys to the flat on 9 January 2020, and a plan was put in place for graduated leave. During day leave in mid-January, Tom came back to the ward having taken the recreational drug, ketamine. This was noted by staff but nothing was changed in terms of his planned leave and planned discharge date in February. 

The leave progressed to two nights of overnight leave beginning on 31 January. Several of Tom’s treating professionals accepted in evidence that an assessment should have been undertaken and recorded before any further leave was granted. This was not done.

Tom was granted seven days of overnight unescorted leave, beginning on 3 February. He was visited the same day by a support worker who came to bring him a supply of medication. 

Tom was hesitant about letting the support worker in. She noted that he was “guarded”, had his hood up, would not give eye contact, his eyes were nearly closed and there was a smell of poppers (amyl nitrate). 

In evidence to the inquest Tom’s psychiatrist, the responsible clinician, accepted that this visit included a number of his recognised triggers and suggested that Tom may be becoming unwell. She conceded that his mental health state should have been assessed, and he should have been recalled to hospital at this point.

The following day, Tom was seen by his psychologist. He told her that he was anxious about a white van on his street outside the flat. He was worried it had monitoring equipment on it and that his neighbours were talking about him and knew who he was. 

Tom raised the same concerns with his father in a phone call that same evening and his father passed these on to the psychologist by email the next morning. 

A multidisciplinary team meeting took place the same day, on the morning of 5 February. The responsible clinician conceded that she had not read Tom’s notes before the meeting and was not aware of his presentation. She also conceded that if she had known about these events, she would have recalled Tom from leave for further assessment. 

The treating professionals had recognised that Tom was particularly vulnerable in the evenings and at night. Tom’s family repeatedly raised concerns with the treating team: that if Tom was discharged to live on his own in private rented accommodation, he would be alone when he was most at risk. Whereas in supported accommodation there would be staff or other residents present during the evening and overnight. 

Tom was last seen by a support worker on 5 February 2020. The following morning, he was found dead as a result of self-inflicted injuries.

Inquest conclusions
The jury found that Tom did not intend to take his own life on 6 February 2020. They also found that the plan to discharge Tom to live alone in private rented accommodation was not in his best interests and that this probably contributed more than minimally to his death. 

The jury also found that the decision to allow him on the seven day period of leave on 3 February, the decision to allow him unrestricted access to knives, and the decision not to recall him back from leave following his presentation on 3 and 4 February (and following concerns raised by his father on 5 February) were not in his best interests and probably contributed more than minimally to his death. 

Claire Creffield, Tom’s mother said: “Senior members of Tom’s care team let him down badly at a time when he was desperately vulnerable. The lessons learned from his death must not simply result in the introduction of yet more paperwork. There needs to be a genuine improvement in clinicians’ ability to hear their patients’ voices, to explore with patients what their needs are, and to meet those needs effectively.”

Gemma Vine, of Ison Harrison Solicitors said: “The evidence that we heard at this inquest demonstrated that Tom’s discharge was at best haphazard and at worst shambolic. Clinicians were unable to confirm who had responsibility in making key decisions and enquiries regarding what type of accommodation would have been in Tom’s best interest upon discharge. 

It was very clear that there was poor record keeping and key decisions regarding assessments as to what would be in Tom’s best interest, particularly relating to accommodation and the support that was required on discharge was at no point recorded in the notes. 

Furthermore, a lack of record keeping and discussions between the multidisciplinary team meant that key concerns about Tom’s presentation whilst on leave were not considered. This resulted in a missed opportunity to recall Tom back to the ward, or at least make a full assessment of his current mental health presentation before his death. Had this happened we fully believe that Tom may not have died that evening.”

Lucy McKay, spokesperson for INQUEST, said: “Tom was receiving care under a mental health Trust that has been widely criticised for its part in many other preventable deaths. He is yet another a young man with autism and mental ill health who has been failed by the NHS. Urgent action must be taken locally and nationally to address the issues identified and ensure this Trust can provide safe care in future.”


For further information contact Lucy McKay on 020 7263 1111 or [email protected] 

The family is represented by INQUEST Lawyers Group member Gemma Vine of Ison Harrison Solicitors and Richard Copnall, of Parklane Plowden, Leeds. The family are supported by INQUEST caseworker Jordan Ferdinand-Sargeant

Other Interested persons represented were Tees, Esk and Wear Valleys NHS Trust.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.

Deaths in Tees, Esk & Wear Valleys NHS Foundation Trust (TEWV)

Between April 2017 and March 2020, the Trust recorded 357 deaths. 

TEWV Governance and care provided during and following this period had been criticised in damning independent investigation reports and a governance report following the deaths of three teenage girls who were detained mental health patients. 

The families of the girls, Christie Harnett, Nadia Sharif and Emily Moore have a campaign, Rebuild Trust, which is calling for a public inquiry into the Tees Esk and Wear Valley NHS Foundation Trust.

The Trust is currently being prosecuted for related failures by the Care Quality Commission.