NHS Trust criticised in death of Carlisle man Nathan Hill - inquest

Nathan Hill, who lived with his parents on Glaramara Drive, was found unresponsive and not breathing at home by his mother, Tracey, on the morning of October 17, 2023.

Mrs Hill called paramedics, but they were unable to revive Mr Hill, and pronounced him deceased at 11am.

A statement given to Cockermouth Coroner’s Court by Mr Hill's father, Paul, described his son as a 'fit and healthy’ child, and a talented sportsman, a ‘really good rugby player’, having been selected to play with Newcastle Falcons.

He played for Morton Manor football team up to the age of 17, as well as being a long-time member of theatre school StagedRight, from the age of five up to 17.

In June 2023, after he had achieved academic success, including a top grade in GCSE English Literature, and landing a job as an apprentice electrical engineer, his father said he became concerned on an occasion when he suspected his son was under the influence of drugs.

On June 19, still aged 17, he was taken by his mother to his GP, where he confessed he had been suffering from anxiety for some time, and had purchased benzodiazepines online to treat this.

The GP stated that they could not prescribe benzodiazepines because of Mr Hill’s age, and the fact that the medication was 'severely addictive', which was validated by Dr Daly, another doctor at Eden Medical Group.

He was also warned of the dangers of buying the medication online, as its contents could not be verified.

Nathan was said to have been a 'really good' footballer. (Image: Supplied)

Mr Hill was offered a prescription of SSRI anti-depressants as an alternative, but declined due to this medication taking around six weeks to have any therapeutic effect.

Assistant coroner for Cumbria, Margaret Taylor, heard that he was referred to the Child and Adolescent Mental Health Services (CAMHS) the same day for assessment.

CAMHS initially rejected the referral, asking the surgery for further information as to how Mr Hill had obtained benzodiazepines.

The surgery supplied the information to CAMHS on June 28.

Ms Taylor heard that until this appointment, his family had 'no idea' about his anxiety.

Mr Hill was heard to have returned to 'his normal self', until around July 13, when his father took him to see a GP at the practice as he believed him to be under the influence of a substance.

His father described this consultation as 'unhelpful', and 'distressing', but this GP contacted CAMHS again that day.

He also refused Mr Hill's request to prescribe benzodiazepines.

Regarding the repeated offering of SSRIs which take weeks to have an effect, Ms Taylor said: "It's not like opioids where you can give methadone as a substitute to help someone going cold turkey.

"There is no easy way of coming off this medication."

Ms Taylor said that Mr Hill's referral to CAMHS was 'finally' accepted by CAMHS on July 20, and on July 24, his father contacted the service as Mr Hill's mental health was deteriorating.

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Ms Taylor said: "Nathan was spoken to by CAMHS on July 26 and the picture presented by Nathan was very different to that given by his father and mother.

"He reported functioning well, he told them he was going to work, he acknowledged use of substances, which I suspect with CAMHS is not an unusual admission for someone his age.

"He said that he didn’t need help, that his anxiety and depression he felt was normal for teenagers his age."

On September 20 he was taken to the Cumberland Infirmary emergency department after again being found under the influence of drugs at home, and was treated for minor physical injuries.

Mr Hill's father told the court that the attendant paramedics were 'very professional', and a 'credit to their organisation'.

Again, contrary to his parents' accounts, he claimed his drug use was 'recreational', and denied any thoughts of self-harm, and so was deemed to have capacity, and having turned 18, was told to self-refer to drug and alcohol services the following day.

Mr Hill told how his son appeared to have 'turned a corner' in the following days, venturing to the Woodrow Wilson pub in Carlisle for 'belated' birthday drinks with friends.

Ms Taylor heard that the day before his death, Mr Hill seemed 'quiet', and 'withdrawn', before the tragic events of the following day.

She accepted the cause of death offered as aspiration caused by inhalation of gastric contents while under the influence of illicit drugs, concluding Mr Hill’s death was by misadventure.

Regarding family concerns over ‘missed opportunities, Ms Taylor said: "The Trust have conceded that there was a significant, and in my view, unacceptable and avoidable delay in ensuring that Nathan was picked up by the service for assessment.

"You as a family could not have done more to express your concerns and agitate on his behalf."

She said that it is 'possible' that this delay could have contributed to his death, but could not be certain.

Ms Taylor said that the waiting time had since been 'significantly reduced', and a 'more robust' triage process was now in place, as well as improvement in GP surgery practices across Cumbria.

She said: "That can't compensate for your enormous loss, but I do hope that you can take comfort that some other families will be spared what you have gone through."