Bethany Hewitt, 34, said she was experiencing ‘suicidal ideation’ during long delays in recieving an assessment
A mum-of-two who told her GP she feared she would be ‘better off dead’ while waiting three years for an ADHD assessment was found hanged, an inquest heard.
Bethany Hewitt said she was experiencing ‘suicidal ideation’ and was ‘bothered by thoughts of hurting herself’ while undergoing long delays in receiving an assessment. During one ‘tearful’ appointment with a GP the 34-year-old said her symptoms were worsening and that she felt ‘very anxious’.
The mum-of-two, of Runcorn, Cheshire, told her doctor she was ‘struggling with tasks and that it was affecting almost everything’.
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Ms Hewitt was found dead on Februry 22 this year. At the time of her death she had still not been assessed – despite being referred in February 2023.
An inquest at Cheshire Coroners Court heard ‘it was known’ there were long waits for assessments. Assistant coroner Sarah Murphy has now issued a prevention of future deaths report warning there was a ‘risk that future deaths could occur unless action is taken’.
Ms Murphy said that on October 31, 2024 Ms Hewitt told her GP at Grove House Practice in Runcorn she was ‘struggling with tasks and that it was affecting almost everything’. A request for an expedited assessment was rejected the following month due to ‘insufficient evidence’.
The rejection letter was sent to the doctors surgery, but not shown to a GP. There were ‘subsequent missed opportunities’ at GP consultations to discover the request had been rejected, the coroner said.
Ms Hewitt attended further GP appointments in November 2025 and February 2026. At the November consultation she said she felt her ADHD symptoms were worsening and that she felt ‘very anxious’. She was prescribed antidepressant Sertraline and advised 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 then told the GP she had been ‘been bothered by thoughts that she would be better off dead, or hurting herself in some way’ but denied an ‘active plans for suicide’.
A follow-up appointment was not made. The inquest heard Ms Hewitt scored 15/27 in the questionnaire. Guidelines indicate that a score of 16 should lead to ‘an urgent referral to specialist mental health services’.
Ms Hewitt was found hanged on February 22. The inquest found ‘the question of intent remains unclear’.
Ms Murphy 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 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 wrote: “I heard evidence that staff levels were impacting on waiting times for a routine and expedited ADHD assessment. I am concerned that staff levels are impacting on waiting times for diagnostic ADHD assessments and is causing significant delays.”
She also said she had heard evidence that there are no national guidelines in relation to the ADHD referral process or expedited assessments. “I am concerned that this may result in an inconsistent approach, and that waiting times may vary across the country, with patients not knowing how long they should be expected to wait for a diagnostic assessment,” she added.
Ms Murphy added: “I am concerned that there is a risk that important external communication is not reviewed by GP’s at the Grove House.”
In response the Department of Health and Social Care said it was ‘deeply sorry’ about the significant delays Ms Hewitt faced. It added: “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 requests for expedited assessments that are declined or where further information is requested, is allocated to a GP for clinical review’.

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