Bethany Hewitt

On 23 February 2026 I commenced an investigation into the death of Bethany Kate HEWITT aged 34. The investigation concluded at the end of the inquest on 02 July 2026. The conclusion of the inquest was that:

Bethany Hewitt was found hanged [REDACTED]. The question of intent remains unclear.

On the 22 February 2026, Bethany Hewitt was found hanged [REDACTED].She had been referred for a diagnostic ADHD assessment to the local ADHD service by the Primary  Care  Mental  Health  Team  on  the  16th  February  2023.  The assessment had not been completed at the time of Ms Hewitt’s death. At the time of the referral, it was known that there were long waits for an ADHD assessment. On the 31st October 2024, Ms Hewitt attended a GP appointment at the Grove House Medical Practice, Runcorn, where she reported that she had been referred for an ADHD assessment in February 2023 and was struggling with tasks and that it was affecting almost everything.  A request for an expedited ADHD assessment was completed by a GP on the 6th November 2024. On the 19th  November 2024, a letter was sent to the GP surgery from the ADHD service stating that the expedited request had been rejected due to insufficient evidence provided within the expedited assessment request form. The letter was not referred to the GP who had requested the expedited ADHD diagnostic assessment, and it was not placed before any other GP. There were subsequent missed opportunities at GP consultations to have discovered that the request for an expedited ADHD assessment had been rejected on the 19th  November 2024. Consideration could then have been given to further reviewing Ms Hewitt for a further request for an expedited ADHD assessment. Ms Hewit attended subsequent consultations relating to mental health issues where follow up reviews had not been requested by the GP. In particular, consultations on the 6th November 2025 and the 3rd February 2026. At the consultation on the 6th November 2025, Ms Hewitt advised that she felt that her ADHD symptoms were worsening, she reported that she was very anxious and was noted to be tearful in the consultation.  She was started on 25mg daily Sertraline and was advised that a side effect of this medication was an increased risk of suicidal ideation. A follow up appointment was not made despite starting this medication. There was also a missed opportunity to consider  offering  the  “Right  to  Choose”  option  for  an  ADHD  diagnostic assessment. On the 2nd February 2026, the Duty Practitioner at the surgery arranged a GP consultation the following day for Ms Hewitt after she had disclosed suicidal ideation on a PHQ9 questionnaire.  In the questionnaire, Ms Hewitt had reported that for several days over the last two weeks, she had been bothered by thoughts that she would be better off dead, or hurting herself in some way. At the GP consultation on the 3rd February 2026, Ms Hewitt  reported that the reasons for her responses in the questionnaires were the wait for an ADHD assessment  and  a  worsening  in  perceived  ADHD  symptoms.  It  was determined that it was not clinically indicated to refer Ms Hewitt to secondary mental health services or for an urgent Mental Health Act assessment. She denied any active plans for suicide.  A “Right to Choose” option was offered at the appointment. In evidence, the GP stated that this was the first time that it had been offered to Ms Hewitt. A follow up appointment was not requested by the GP on the 3rd  February 2026, when the score from the PHQ 9 questionnaire was 15/27. In evidence, I heard that NICE Guidelines recommend an urgent referral to specialist mental health services where there is “more severe depression “ which is evidenced by a PHQ score of 16 or more. Ms Hewitt’s mental health was not monitored after the GP consultation on the 3rd  February 2026, but she had confirmed that she had emergency mental health telephone numbers. 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.

In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action.