A mother of two told her GP she feared she was "better off dead" while waiting years for an ADHD assessment, an inquest has heard. Bethany Hewitt, 34, died on February 22 this year, still without having been assessed, despite being referred in February 2023.
GP consultations and missed opportunities
At an inquest at Cheshire Coroners Court, it was heard that Ms Hewitt reported "suicidal ideation" and was "bothered by thoughts of hurting herself" during a "tearful" appointment. She felt her symptoms were worsening and felt "very anxious", and reported she was "struggling with tasks and that it was affecting almost everything".
Assistant coroner Sarah Murphy said that on October 31, 2024, Ms Hewitt told her GP at Grove House Practice in Runcorn she was struggling with tasks. A request for an expedited assessment was rejected the following month due to "insufficient evidence". The rejection letter was sent to the surgery but not shown to a GP, and there were "subsequent missed opportunities" at GP consultations to discover the request had been rejected.
Further appointments and questionnaire
Ms Hewitt attended further GP appointments in November 2025 and February 2026. At the November consultation, she said her ADHD symptoms were worsening and she felt "very anxious". She was prescribed the antidepressant Sertraline and advised that a potential side effect was an "increased risk of suicidal ideation".
Before the February appointment, Ms Hewitt disclosed suicidal ideation on a questionnaire designed to diagnose and measure depression. She told the GP she had been "bothered by thoughts that she would be better off dead, or hurting herself in some way" but denied having "active plans for suicide". A follow-up appointment was not made. The inquest heard Ms Hewitt scored 15 out of 27 on the questionnaire; guidelines indicate that a score of 16 should lead to an urgent referral to specialist mental health services.
Coroner's concerns and response
Ms Murphy issued a prevention of future deaths report, warning there was a "risk that future deaths could occur unless action is taken". She wrote: "It is likely that the long wait for an ADHD diagnostic assessment and a worsening in perceived ADHD symptoms contributed to the decline in Ms Hewitt's mental health."
The coroner said that in 2024, the ADHD service in Halton, Cheshire, to which Ms Hewitt had been referred, had more than 1,250 people awaiting assessment. Over the last two years, the service has seen a 600% increase in referrals. Ms Murphy said she was concerned that staff levels were impacting waiting times for diagnostic ADHD assessments, and that there were no national guidelines for the referral process or expedited assessments, which could lead to inconsistent approaches and varying waiting times across the country.
The Department of Health and Social Care said it was "deeply sorry" about the significant delays Ms Hewitt faced, adding: "The government recognises that, nationally, demand for ADHD assessments has grown significantly in recent years and that people are experiencing severe delays for accessing such assessments."
Grove House Practice said it had amended its correspondence management policy to ensure that any correspondence relating to the outcome of a referral, including declined requests for expedited assessments, is allocated to a GP for clinical review.
