A coroner has criticised a general practitioner for failing to send medical records to mental health services months before a 37-year-old father, Adam Craddock, died by suicide. 

Mr. Craddock, originally from Yeovil in Somerset, was found dead at his home in Blackburn on May 10. He had a history of acute transient psychosis, a condition characterized by the sudden onset of psychotic symptoms. Adam had relocated to the Langho area of Blackburn, where he lived with his partner, Heather, and their daughter. 

An inquest held on Monday, November 18, at Blackburn Town Hall revealed that two days before his death, Adam told Heather he wanted to end their relationship. He cited "brain fog" and a fear of early-onset dementia, though Heather tried to reassure him that his symptoms were linked to depression. 

On May 9, Adam did not go to work and stayed home the next day. When Heather returned home around 5 p.m. on May 10, she found him unresponsive, and he was later pronounced dead. The inquest noted that Adam had no history of self-harm or suicide attempts, though he sent his mother a text before his death apologizing for being "so s*** all these years." 

The court heard that in November 2022, the mental health Initial Response Service had requested Adam's medical records from his GP after a consultation. However, the records were never sent, leading to his discharge from mental health services. 

Dr. Padma Chennubhotla, Adam's GP, admitted during the inquest that "maybe" the surgery should have followed up when the mental health trust chased the records. Assistant Coroner Laura Fox criticized the lack of action, stating: 

"It is concerning to me that whilst acknowledging there was an 'oversight,' you could have followed it up. It ought to have been done, full stop. A lot of this comes down to ownership and responsibility. Lessons must be learned, and record requests must be actioned expeditiously." 

A Rapid Learning Review by Lancashire and South Cumbria NHS Foundation Trust, which oversees mental health services, was conducted following Adam's death. The review noted that as of November 2023—12 months after the request—Adam's GP records, which included details of his acute transient psychosis, had still not been received. The review acknowledged that clarifying Adam’s diagnosis may have been "helpful" but concluded it was unlikely to have altered the outcome. 

Assistant Coroner Fox returned a conclusion of suicide, stating: 

"Adam Craddock did intend to end his own life, and he succeeded by the means that he adopted." 

Following Adam's death, Clifton Rugby Club, where he had been an active member between 2011 and 2015, expressed condolences in a heartfelt online post: 

"As a club, we are deeply saddened to face the loss of Adam, who was a hugely liked and valued member of the Wanderers and club 7s sides. We extend our heartfelt sympathy and condolences to Adam’s partner and his daughter."