A coroner has ruled that there were failings in the care provided to former England cricketer Graham Thorpe in the months leading up to his death, recording a conclusion of suicide.
Surrey Coroner’s Court in Woking heard that healthcare professionals did not perceive Thorpe to be in a “crisis situation,” even after being informed that he had asked his wife “for help to end his life” weeks before his death.
Thorpe, 55, widely regarded as one of England’s finest players of his generation, died on 4 August 2024 after being struck by a train at Esher railway station in Surrey.
Coroner Jonathan Stevens acknowledged “shortcomings” in Thorpe’s care, but stated that these did not constitute gross misconduct.
The court was informed that Thorpe had “spiralled into depression” following the loss of his position as a batting coach and had previously attempted to take his own life.
Care co-ordinator Katie Johnson spoke to Thorpe’s wife on 28 June, after he missed an appointment with the community mental health team. His wife reported that Thorpe was “constantly asking for help to end his life”, the court heard.
Ms. Johnson then spoke with Thorpe, who stated that he “hadn’t been out for a while” and “didn’t see the point of being here,” but denied having any immediate plans to act on suicidal thoughts, according to the inquest.
The coroner noted that the last in-person consultation between the cricketer and healthcare professionals occurred on 20 March.
“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 stated.
He added, “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.”
Following Thorpe’s death, Surrey and Borders Partnership NHS Foundation Trust conducted an investigation.
Dr. Shriti Burgul, a consultant psychiatrist who reviewed the investigation’s report, testified that one of the findings was that “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.”
When questioned if arranging an appointment in two weeks was an appropriate response, Dr. Burgul stated that, in the absence of a patient expressing “active intent” or an “active plan,” allowing two weeks would be appropriate.
She informed the court that Thorpe’s condition did not warrant intervention from the home treatment team.
The psychiatrist was asked if there was any evidence that an in-person assessment would have resulted in a different outcome, to which she replied, “no.”
The investigation highlighted a letter from Thorpe’s discharge from a private hospital in July 2022, recommending that a neuropsychologist be identified to provide further support, the inquest heard.
Given that the conversation on 28 June was conducted over the phone, the psychiatrist was asked if it would have been appropriate to arrange to see Thorpe quickly.
She told the court: “In the wisdom of hindsight, then yes, a home visit would have been clinically indicated.”
Dr. Burgul told the court that neither the private provider nor the GP ever conducted a home visit, and a risk panel advised that it should be explored in June 2024.
When asked if any neuropsychological impact could have affected the cricketer’s ability to engage in appointments, given that he missed some, the psychiatrist replied, “It’s a possibility, yes.”
The coroner stated that a pathologist recorded Thorpe’s cause of death as multiple injuries.
Thorpe’s widow stated that the termination of his employment with the England and Wales Cricket Board had been a “real shock to Graham,” marking the “start of the decline of his mental health.”
Mrs. Thorpe described her husband as her “best friend and soulmate.”
Following the conclusion of the inquest, she issued a statement saying, “We will never get over the tragic loss of Graham, and we miss him every day.”
“Next Friday would have been Graham’s 56th birthday, and we plan to celebrate his life at the Oval.”
Mrs. Thorpe announced that the family would gather with the charity Mind to raise funds to help people affected by mental health illness.
“We would like to reduce the stigma and shame felt by sufferers, especially middle-aged men,” she added.
She said the event was to also raise awareness of people who are supporting families and friends living with mental health issues.
Additional reporting by PA Media.
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