NHS trust makes changes to mental health services following death of 21-year-old

Isaac Eastwood during a trip to the Amala children's home in India.

The family of a young Wensleydale man, who died after falling from a cliff, say they are relieved that an NHS trust which cared for him has made changes following the tragedy.

An inquest into the death of Isaac Lawrence Eastwood, from Leyburn, held last week in Northallerton, found that the 21-year-old intended to take his life when he fell from Malham Cove on 19 July, 2018.

Isaac was receiving help for mental health issues from Tees Esk and Wear Valleys NHS Foundation Trust after being diagnosed with bipolar affective disorder in July 2017

The inquest heard evidence that nine days before his death, Isaac was assessed by both his care co-ordinator and the trust’s crisis team.

It was agreed that intensive home treatment was required and he was placed on ‘red risk status’ to monitor his risk. However, two days later his risk status was reduced.

Evidence was heard that on July 16, three days prior to Isaac’s death, his care co-ordinator recommended that he be admitted to hospital due to a decline in his mental health.

However, the crisis team did not agree. They contacted Isaac that evening via telephone but did not insist on seeing Isaac the next day for a face to face review.

On the July 18 Isaac received a visit from a consultant psychiatrist from the trust who changed his diagnosis in relation to his mental ill health.

The inquest heard that Isaac was shocked and upset by the change. His family were left to deal with this news and the effect it had on Isaac.

Recording a narrative verdict that Isaac had intended to end his life, assistant coroner Jonathan Heath concluded that errors made in the care of Isaac did not amount to systemic or operational failures.

The hearing heard that following Isaac’s death a serious incident report (SIR) was conducted which found a significant number of areas where the trust could have provided better care to him.

The inquest heard that an action plan had been put together to improve weaknesses found in the report.

Following the conclusion of the inquest, Isaac’s father, Simon Eastwood, said: “As a family we feel we have honoured the memory of our beloved 21 year old son and feel the inquest process has allowed the issues to be heard and allowed us to share some of the pain and trauma we have experienced.

“We were shocked and dismayed when we received the serious incident report, which highlighted the root causes and the areas of improvement.

“We are relieved that these have been positively addressed as part of the action plan and staff members have been trained further following the death of Isaac and new procedures are in place which will go some way in improving mental health care.”

Sara Lyle, of Minton Morrill solicitors, who represented the family at the inquest, said: “The SIR concluded that there was four fundamental factors that had a direct effect on Isaac’s death occurring which included the lack of appropriate consideration and acknowledgement of the nature, degree and severity of the risks that Isaac presented with.

“It is regrettable that the coroner has not identified any failings in his conclusion however, the family are appreciative of the opportunity to seek answers to the questions that they had in relation to the care that Isaac received.”

Jennifer Illingworth, director of quality governance for Tees, Esk and Wear Valleys NHS Foundation Trust, said: “Our thoughts are with Isaac’s family and friends at this distressing time.

“We always carry out a review when someone under our care dies to establish how we could do things differently in the future.

“Following this we have taken measures to address recommendations that were highlighted and will continue to monitor them to ensure these actions are working effectively.”


  1. Who do we contact who can help us with our son? We have the same problem and we are getting no help for him and it’s not being taken seriously. Desperate plea from a mother.

    • Hi Chantelle, I would approach your GP in the first instance but if things are desperate then go straight to A&E and meet with the Crisis Team.Wishing you and your family all the best in this.

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