AN inquest has heard there were four areas required for improvement after a patient took his own life nine days after a previous attempt.

Popular lay minister Gareth Douglas-Brown was admitted to the West Cumberland Hospital in Whitehaven on August 15, 2019, following an overdose overnight.

Mr Douglas-Brown had told those who treated him he had intended to take his own life, the inquest in Cockermouth heard yesterday.

It was said he had suffered from depression on and off for the last 15 years and that he had been asked to leave the family home a week before and he was living with his mother.

His deteriorating mental health had put a strain on his marriage.

“He stated that he did not want to repeat the overdose and he thought the family support was a force against future overdoses,” outlined Dr Watts, who treated Mr Douglas-Brown, in her statement.

After being treated at the hospital, he was then passed onto the care of the Cumbria Partnership NHS Foundation Trust’s mental health team, a service which is now managed by the Cumbria, Northumberland, Tyne and Wear (CNTW) NHS Foundation Trust.

After an assessment Mr Douglas-Brown was discharged to the care of his GP, a decision agreed with the patient.

The inquest heard how Mr Douglas-Brown had told those who assessed him that he would continue with his programme of private counselling and would refer himself to his GP.

Nine days later, he ended his own life. He was 41.

Following his death, an investigation was carried out, which was detailed by David Muir, group director at Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust.

A statement read on his behalf told the hearing the assessment carried out on Mr Douglas-Brown following the first attempt to take his own life failed in four areas.

He said documents were not completed detailing the reasons behind why Mr Douglas-Brown was not referred to the NHS trust’s 72-hour pathway, a period of close supervision and treatment.

The assessment was not referred to the Access and Liaison Integration Service (ALIS)’s multi-disciplinary team meeting, where the patient evaluation would be discussed.

A GRiST assessment – which looks at and manages the risks of suicide and self-harm – was not carried out promptly; and the patient assessment was also not sent to Mr Douglas-Brown’s GP, again against NHS practice.

However, Craig Smith, assistant coroner for Cumbria, told the inquest: “I am confident the shortcomings on his visit to hospital on August 15 have now been addressed.”

Mr Smith said on the balance of probabilities that Mr Douglas-Brown had intended to take his own life, pointing to his internet history in the weeks leading up to his death and the suicide note left at the scene.

The assistant coroner said he did not believe that the ‘shortcomings’ contributed to Mr Douglas-Brown’s death.

He marked a formal conclusion of suicide.