Graham Thorpe's care had 'failings' in last months of his life, says coroner

The Guardian

a day ago

There were 'failings' in the provision of former England cricketer Graham Thorpe's care in the months before he died, a coroner has said, as a conclusion of suicide was recorded at an inquest.
Thorpe, 55, died on 4 August 2024 after being struck by a train at a railway station in Surrey.
He had 'spiralled into depression' after losing his job as a batting coach in 2022, and tried to take his own life on another occasion, Surrey coroner's court heard. He also asked his wife for help to end his life.
The coroner, Jonathan Stevens, said the last time Thorpe was seen in person by healthcare professionals was on 26 March 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,' he said.
Stevens added that 'there were failings in the provision of his care', but said that, on the evidence, he could not conclude those failings were gross and that, without them, Thorpe would not have died. He said healthcare appointments were offered to Thorpe, but he 'found it hard to attend these' because of his mental health.
Stevens found that 'someone should have gone to see him to properly monitor and assess him, to do a face-to-face risk assessment and understand and address his care needs as required by the care plan'.
The inquest heard that healthcare professionals did not consider Thorpe to be in a 'crisis situation' after he missed an appointment with the community mental health team on 28 June. At the time, Thorpe's wife, Amanda, told his care coordinator over the phone that her husband had been asking her 'for help to end his life'.
During the same phone consultation, Thorpe said 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 his suicidal thoughts.
The coroner said: 'I don't accept that when Graham was constantly asking his wife to help him end his life, which was a new presentation … that he was not at that point in crisis.
'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.'
In May 2023, Thorpe had suicidal thoughts and was given inpatient treatment. Stevens said that 'some similar protective measures should have been considered in June 2024'.
An investigation was carried out by Surrey and Borders Partnership NHS trust after his death.
Thorpe was a mainstay of the England men's cricket team for many years, as a batter between 1993 and 2005, and then as a coach for 12 years.
During his international career, he struck 16 Test hundreds for England, including a debut century against Australia at Trent Bridge in 1993. In all formats, he represented his country 182 times.
Amanda Thorpe told the inquest the termination of his employment with the England and Wales Cricket Board was a 'real shock to Graham', which was the 'start of the decline of his mental health'.
Speaking outside the coroner's court, she said: 'We will never get over the tragic loss of Graham, and we miss him every day. He was my best friend, my soulmate, and he was just a joy. And he loved life – but he got very ill.'
Mark McGhee, the family's legal representative, said the coroner had found 'significant shortcomings' in the care provided. He said Thorpe's family 'hope that the coroner will address these concerns' so that such a loss 'never happens again'.
Jo Lynch, the chief nursing officer for the Surrey and Borders Partnership NHS trust, said: 'We are deeply saddened by the tragic death of Graham Thorpe and our thoughts are with Graham's family and loved ones.
'We will reflect on the coroner's findings and our role in Graham's care with a view to continuous improvement and learning.'
In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email [e-mail] or [e-mail]. In the US, you can call or text the National Suicide Prevention Lifeline on 988, chat on 988lifeline.org, or text HOME to 741741 to connect with a crisis counselor. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org