Suicide father was 'tortured' by tinnitus

CROSSING . . . The Moorgate Halt crossing near Greenfield station in Saddleworth

THE family of a father and businessman who took his own life after suffering with sleep deprivation and anxiety caused by tinnitus believe he was let down by medical practitioners shortly before his death.

Karl Peter Stevenson (46), of Shaw Bank Hall Road, Greenfield, stepped out in front of a train at the Moorgate Halt crossing near Greenfield station on November 3, 2016.

Emergency services arrived swiftly, but Mr Stevenson was pronounced dead at the scene.

Mr Stevenson was described by his wife Joanne as a kind person to whom family was the most important thing in his life.

An inquest at Heywood Coroners' Court heard Mr Stevenson, who had a sign-building business, had been fit and healthy all his life, until January 2015 when an appointment with his GP revealed he had high blood pressure.

He was told to monitor it at home, and he did not see a doctor again until September 27 last year. He then prescribed tablets for high BP on October 11.

The tablets, he claimed, were a direct cause of his tinnitus, a condition that would cause him much anxiety and sleep deprivation, leading to a downward spiral.

Mrs Stevenson believes the elevated blood pressure readings may have been down to her late husband having white coat syndrome - a condition which makes a person's blood pressure higher when it is taken in a medical setting than it is when taken at home. This condition was not recorded in the doctor's notes, which has left the family puzzled.

Mr Stevenson also suffered from ocular migraines, which involves visual disturbance often without a headache.

Dr Ruskin Hartley, one of Mr Stevenson's GPs at Saddleworth Medical Practice, explained this neurological condition may have been the reason why another doctor at the practice, Dr Bibi, had prescribed the BP tablets, rather than taking his BP again.

He also said it was possible, although not probable, that the BP tablets had caused Mr Stevenson's tinnitus.

Coroner Lisa Hashmi said it would have been "pertinent" for the doctor to have had a discussion with Mr Stevenson about the pros and cons of starting such medication, given that he was young in age and this would have been long-term medication to manage his blood pressure.

Confusion

Another major concern raised by Mr Stevenson's family was around his mental health. Mr Stevenson, accompanied by his wife, told Dr Hartley, on November 1, he had been having suicidal thoughts and feelings, although he said he had not planned to take his life.

Mrs Stevenson wanted someone to see her husband that day, but there seemed to be confusion as to where to send him.

She said: "He never had any mental health problems. For something to affect him was a massive thing. It took over our lives.

"He explained how he was feeling to the GP. He was told if you are suicidal then go to A&E or refer yourself to Healthy Minds. We did come away thinking that we didn't get that much help."He said if there was a switch he wished he could switch it off. He said if he was not the dad he had been  he would rather not be here.

"He wasn't the type of person you would imagine doing something like that. I knew he needed help.

"If they had monitored his BP a little bit more, he may not have had to take those tablets and then get tinnitus in the first place.

"He felt like he was being tortured. There was no escape from the noise. He was felt like no one was there to help, no one was getting it."

Coroner Mrs Hashmi asked Dr Hartley if the "single point of entry", which provides an easy access route into mental health services, was used effectively as it is available for all GPs. He went back and forth between the RAID team at the Royal Oldham Hospital A&E and the access crisis team.

When the couple went to A&E the staff were not aware that Mr Stevenson was supposed to be arriving. Mrs Stevenson said the GPs should call the team beforehand to let them know that the patient should be arriving.

Mrs Hashmi said to Dr Hartley: "You were given the run around and on more than one occasion. It's not acceptable. It's not safe for your patients. If a GP has concerns why can't they go directly to a psychiatric team?"

The couple were at A&E for nearly three hours and it would have been another three hours before they could get help. As Mr Stevenson was feeling agitated they thought it was best to go home.

The day before his death, Mr Stevenson called his best friend Aaron Miller, telling him he was at the quarry near his home and intending to take his own life.

Mr Miller managed to calm down his friend and told him he would see him at his home, then rushed from Manchester to Saddleworth.

At Mr Stevenson's home, Mr Miller told him being a DJ had also left him with tinnitus, but he was managing the condition and so could Mr Stevenson.

Mr Miller helped make a plan with his friend to reassure him before he took his sleeping tablets and went to sleep.

Mr Stevenson coped better after taking sleeping tablets, but felt they were only a short-term solution.

Mr Miller said: "He felt like he couldn't live with the noise anymore. I said it's not the noise that's the problem it's the lack of sleep. I was in disbelief that this could be Karl. I wish I had stayed there that night."

On the morning of his death, Mr Stevenson told his wife he was going out on his bike. She texted him to say if he was still feeling low they would go to A&E. He replied, "I won't be long", shortly before ending his life.

A witness told police he saw Mr Stevenson at the crossing, looking upset with his face in his hands. Police searched his iPad, which showed he had been looking up ways to end his life as well as how to get help.

Mrs Hashmi made a regulation 28 report regarding the mental health referral process adopted by the practice and how GPs access the "single point of entry" to ensure other patients suffering from mental health problems would not have the same tragic fate as Mr Stevenson.

Giving the conclusion of suicide, Mrs Hashmi said: "I agree with the family that Karl did not set out that day to take his own life. He had thoughts, but no obvious plan.

"On the balance of probabilities he made a split-second decision. He saw the train line and that was it, the decision was made. Despite the difficulties arising out of the referral process in terms of getting to see a psychiatrist. I don't believe Karl's death could have been prevented."