AN 'adored father' took his own life after a ‘sub-optimal’ mental health assessment, a coroner ruled.

Christopher Crosthwaite, 40, from Walney, died on October 12, 2021, after he stepped onto the railway line near Furness Abbey having come out of an assessment at Dane Garth, Furness General Hospital.

Coroner Kirsty Gomersal ruled the death as suicide at an inquest heard at Cumbria's Coroners' Court in Cockermouth. The inquest, which was opened 32 months ago and has been through multiple hearings, was concluded by Ms Gomersal on Friday (June 7). 

Ms Gomersal said both it being deliberate act and intent had been found on the balance of probabilities and that in the days leading up to him taking his life, he had experienced low mood and symptoms of depression. 

The court heard he had struggled with his mental health for several years and had previously experienced psychosis.

On the day of his death, Mr Crosthwaite had an appointment with mental health practitioner Jayne Braithwaite.

His partner and carer Jennifer Thomson was told she could not attend his appointment for Covid-related reasons, the inquest heard.

The court had access to CCTV footage with audio of Ms Braithwaite's assessment of Mr Crosthwaite. The court heard the fact that the CCTV camera had audio was unknown to the trust until the start of an investigation.

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The camera has since been removed, the court heard. 

Ms Gomersal said: "This would have been a very different inquest without the CCTV."

During the meeting, Mr Crosthwaite told her his mental health had been deteriorating.

He was asked if he had any thoughts of harming himself or others but told Ms Braithwaite: 'No'.

Ms Braithwaite said there was no evidence of 'thought disorder' and she felt he demonstrated forward planning.

In January, Ms Braithwaite accepted she interrupted Mr Crosthwaite on occasions. That session heard that Ms Braithwaite told Mr Crosthwaite: "You're not at the bottom yet" and told him to go to his GP and gave him the number of the 24-hour emergency line if he needed help. 

The court heard he only had a pound in his pocket and a piece of paper after the appointment.

In the previous session, Ms Braithwaite said: "I genuinely did not think he was suicidal. He was quite adamant about that," adding: "I didn't feel he was in crisis."

In a January hearing, Ms Thomson told the court she was 'really cross' she received a call from Ms Braithwaite telling her her partner had been discharged and was walking home to Walney when she had gone home expecting the consultation to last up to 90 minutes. 

Ms Gomersal said the assessment was 'sub-optimal'. However she said it was ‘not safe for me to find there was a gross failure to provide care.’

Ms Gomersal said she would not make a report to prevent future death as the trust's findings were 'sufficient'.

Mr Crosthwaite was described as an 'adored, brilliant and fun dad' and a 'talented sportsman' with 'many friends'.

"My deepest condolences. Chris was clearly a very special person," Ms Gomersal said to the family who were in attendance. 

Ursula Martin, Chief Strategy and Improvement Officer at Lancashire and South Cumbria NHS Foundation Trust (LSCft), said: “We fully acknowledge the conclusion reached by HM Coroner in relation to the sad death of Christopher (Chris) Crosthwaite and I would like to extend my deepest condolences to his family.

“After Chris’ death in 2021, we have made several improvements which we were able to share at his inquest.

“We conducted a comprehensive investigation, identifying care delivery issues on the day Chris passed away which fell below the standard we expect and train our staff to undertake. As a result, we have delivered further training to our staff, reminding them of their duties when assessing patients and the quality of information they record in their notes.

“In addition, we place an even stronger emphasis on the patient experience and the involvement of family and carers in assessments, as well as in the on-going support of their loved ones under our care. They are very important in that process.

“Once again, my thoughts remain with Chris’ loved ones at this difficult time.”

Anyone feeling distressed or suicidal can call the Samaritans helpline on 116 123.