Health professionals failed Thorpe
Mr Thorpe was not perceived by healthcare professionals to be in a "crisis situation" after they were told he had asked his wife "for help to end his life" weeks before he died, Surrey Coroner's Court in Woking heard.
The 55-year-old was regarded as one of the best English players of his generation.
He died on the morning of 4 August 2024 after being struck by a train at a railway station in Surrey. Coroner Jonathan Stevens said there had been "shortcomings" in Mr Thorpe's care, but they did not amount to gross misconduct.
The court heard Mr Thorpe had "spiralled into depression" after losing his job as a batting coach, and he had tried to take his own life on another occasion.
After Mr Thorpe missed an appointment with the community mental health team on 28 June 2024, care co-ordinator Katie Johnson spoke to Mrs Thorpe on the phone, who said her husband was "constantly asking for help to end his life", the court heard.
Ms Johnson then spoke to Mr Thorpe who told her he "hadn't been out for a while" and "didn't see the point of being here" but had no immediate plans to act on suicidal thoughts, the inquest heard.
'Shortcomings in care'
The coroner said that the last time Mr Thorpe had been seen in person by healthcare professionals was on March 20 2024.
"In my judgment there were shortcomings in the care that should have been provided to Graham in the last four months or so of his life," Mr Stevens said.
He added "there were failings in the provision of his care" but added he could not conclude that if it were not for the failures Mr Thorpe would not have died.
"It's clear there were shortcomings in his care. If he had been seen in those last four months, particularly after that incident on 28 June, I cannot say whether it would or would not have made any difference," he added.
An investigation was carried out by Surrey and Borders Partnership NHS Foundation Trust after Mr Thorpe's death.
Dr Shriti Burgul, a consultant psychiatrist who reviewed the investigation's report before it was finalised, told the court on Friday one of the findings was "it was noted Mr Thorpe's presentation at his appointment on 28 June 2024 was in keeping with previous presentations and not perceived by the team as a crisis situation".
Asked if arranging an appointment in two weeks was an appropriate response, Dr Burgul said that in the absence of Mr Thorpe expressing "active intent" or an "active plan" it would be appropriate to allow two weeks.
She told the court Mr Thorpe was not at the level of requiring intervention from the home treatment team.
The psychiatrist was asked if there was any evidence that - if there had been an in-person assessment for Mr Thorpe - there would have been a different outcome, and she replied "no".
The investigation noted a letter from when Mr Thorpe was discharged from a private hospital in July 2022, which said a neuropsychologist should be identified to provide further support, the inquest heard.
'A real shock'
Given the conversation was over the phone, the psychiatrist was asked if it would have been appropriate to arrange to see Mr Thorpe very quickly.
She told the court: "In the wisdom of hindsight, then yes, a home visit would have been clinically indicated."
This was never done by the private provider or the GP, and a risk panel advised it should be explored in June 2024, Dr Burgul told the court.
Asked whether there was any neuropsychological impact that could have affected the cricketer's ability to engage in appointments, given he missed some, the psychiatrist said: "It's a possibility, yes".
Mr Thorpe's cause of death was recorded by a pathologist as multiple injuries, the coroner said.
His widow said the termination of his employment with the England and Wales Cricket Board had been a "real shock to Graham", which was the "start of the decline of his mental health".
Reported by PA Media
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