KEVIN CONRAD GALE · Prevention of Future Deaths report

Mr Kevin Conrad GALE died on 4 March 2022 at his home address.

An inquest into Mr Gale’s death was opened on 22 March 2022 and his inquest was heard before me on 2 November 2023.

The medical cause of Mr Gale’s death was:

1a Hanging

The determination was:

Mr Kevin Conrad Gale died on 4 March 2022 at his home address, 8 Langton Court, Penrith as the result of deliberate self-suspension ████████. Mr Gale had a long history of low mood and anxiety. He was engaging with mental health services and had been diagnosed with severe depression and anxiety. Mr Gale was taking his medication but was still struggling to manage anxiety. Although Mr Gale denied suicidal intent, on the evidence and on the balance of probabilities, Mr Gale intended to take his life.

The conclusion of the inquest was:

Suicide

Mr Gale was detained under Section 2 Mental Health Act in November 2021 and was discharged from that section on 4 January 2022. Mr Gale was diagnosed with severe depression and anxiety. Mr Gale was seen regularly by mental health professionals and was in frequent contact with mental health services. Those services were provided by Cumbria, Northumberland Tyne & Wear NHS Foundation Trust (”the Trust”). Mr Gale was compliant with his medication and engaged with services. He was well supported by his family and friends.

Mr Gale’s anxiety continued during his engagement with mental health services. Evidence was heard about what caused Mr Gale’s anxiety. One ongoing feature was his application for Universal Credit.

On 2 March 2023, 2 days before his death, Mr Gale was seen by an Associate Specialist Psychiatrist, who gave evidence at the inquest. The Psychiatrist considered Mr Gale’s anxiety was exacerbated by his application for Universal Credit. During Mr Gale’s appointment, the Psychiatrist called the benefits office for help but the call was not answered before the end of the consultation. Mr Gale was expecting a call from a DWP representative the next day (3 March).

On 3 March 2022 at approximately 11:00 am, Mr Gale spoke to the duty Registered Mental Health Nurse. He remained very anxious and his main concern was the application for Universal Credit.

During their evidence, the Associate Specialist Psychiatrist expressed concerns about the experience of mental health service users with DWP. These concerns were not just specific to Mr Gale.

Evidence was also given by the Trust’s Group Nurse Director (a Registered Mental Health Nurse) who considered that the issues identified by the Psychiatrist were national. The Director considered it important to address these issues as they were debilitating for service users.

The Director advised that the Trust’s Crisis Team had started a food bank 3 years ago to support service users. The Director was also aware that the DWP had been invited to the Cumbria Suicide Prevention Group.

I stress that I did not make a causal link between Mr Gale’s death and his anxiety about his Universal Credit application. DWP was not an Interested Person in Mr Gale’s inquest and did not give evidence as the concerns raised did not come to light until the hearing.

Current DWP procedures may not be practical for those with mental health illness and can exacerbate symptoms. I heard evidence that:

1. The number of and length of DWP forms required to be completed can be overwhelming for someone with a mental health illness. This is perpetuated if the applicant cannot get help to complete the paperwork.
2. There are long telephone queues to speak to a DWP advisor.
3. Having to travel long distances for appointments can be detrimental for those with a mental health illness.