She Waited Three Years for an ADHD Assessment. It Cost Her Everything.
She Waited Three Years for an ADHD Assessment. It Cost Her Everything.
Bethany Hewitt did what she was supposed to do. She went to her GP. She asked for help. And then she waited.
For three years.
On 22 February, the 22-year-old was found dead in her home in Runcorn, Cheshire. She had taken her own life. Three years earlier, in February 2023, she had been referred for an ADHD assessment. She never got one.
The timeline is devastating in its ordinariness. On 3 February, just 19 days before her death, Hewitt told a GP at Grove House Medical Practice that she was having thoughts about hurting herself. She had been bothered for several days by the feeling that she would be “better off dead.” A questionnaire used to screen for depression gave her a score of 15 out of 27 — a result indicating moderately severe depression.
She was already on a waiting list that stretched back years. And it would never end.
A System Under Siege
Cheshire assistant coroner Sarah Murphy didnt mince words in her Prevention of Future Deaths Report. She pointed to large backlogs of ADHD assessments, insufficient staffing levels, and a lack of National Institute for Health and Care Excellence guidelines governing the referral process.
The numbers tell their own story. In 2024, the ADHD Service Halton, operated by North Cheshire and Mersey NHS Foundation Trust, had over 1,250 patients waiting for assessment. Referral rates were running at more than 100 per month. Over the past two years, the service had seen a 600% increase in referrals — a surge that mirrored what was happening to ADHD services across the country.
“Sustained high demand” is the phrase Murphy used. It sounds clinical. It reads like a bureaucratic hurdle. But behind those two words are people — over a thousand of them in Halton alone — waiting for answers that might help them understand themselves, manage their lives, and, in some cases, stay alive.
Grove House Medical Practice tried to expedite Hewitts assessment. The request was rejected. The reason given: insufficient evidence provided within the form. A clerical decision. A box not ticked correctly. Another door closed.
Murphy also flagged the absence of national NICE guidelines for ADHD referrals, noting that this leads to an inconsistent approach across the country. Waiting times vary wildly depending on where you live. Patients have no idea how long theyll be expected to wait. Theyre left in limbo, told to be patient, while their mental health deteriorates.
The Space Between Referral and Diagnosis
Theres a particular kind of cruelty in waiting for a diagnosis that might explain your entire life. ADHD isnt just about difficulty concentrating or being easily distracted. It affects emotional regulation, impulse control, relationships, employment, self-esteem. Its linked to higher rates of anxiety, depression, and — as this case tragically demonstrates — suicidal ideation.
For Hewitt, the wait wasnt just an inconvenience. It was a period of acute vulnerability with no safety net.
When she finally told her GP she was having suicidal thoughts, the system knew she was at risk. She scored as moderately severely depressed. And yet, 19 days later, she was dead. The referral that might have led to treatment, to support, to some semblance of understanding, was still somewhere in a queue that had no visible end.
Murphys conclusion is blunt: “In my opinion, unless action is taken to address the above concerns then there is a significant risk of further deaths, and I believe each of you have the power to take such action.”
She directed her report to both Grove House Medical Practice and the Secretary of State for Health and Social Care. The message is clear: this isnt just a tragedy. Its a warning.
What Happens Now
The Department for Health and Social Care offered its “sincere condolences” to Hewitts family and said it had launched a review into ADHD services. Results are due shortly and will, according to the department, “inform future government decisions and policy development.”
Grove House Medical Practice said it would record the case to “ensure that the learning from this tragic event is shared beyond the practice and contributes to wider system learning.” It added that it was “committed to working collaboratively with other organisations to ensure that learning from this case results in meaningful improvements to patient safety.”
NHS England said it would ensure “key learnings and insights around events” are shared across the service to “help us to pay close attention to any emerging trends that may require further review and action.”
These are the right things to say. They are also, almost word for word, the things that get said after every preventable death. The question is whether anything changes before the next one.
The demand for ADHD assessments isnt going away. If anything, its growing as awareness increases and stigma decreases. Thats a good thing. People are recognising themselves in descriptions of ADHD and seeking help. But the system wasnt built for this volume, and its buckling under the weight.
The Cost of Waiting
What makes this case so haunting is how avoidable it feels. Hewitt did everything right. She sought help. She was honest about her struggles. She was flagged as at risk. And still, she fell through the cracks.
The coroners report makes it clear that the cracks are structural. Theyre not the fault of any one GP or administrator. Theyre the result of underfunding, understaffing, and a lack of national guidance that leaves patients and clinicians alike navigating a maze with no map.
But structural problems require structural solutions. And those solutions need to come from the top.
The review into ADHD services is a start. But reviews have a habit of producing recommendations that gather dust. Whats needed is action: proper funding, clear NICE guidelines, and a system that treats waiting lists as what they are — not just numbers, but people whose lives are on hold.
Hewitts death is a tragedy. Its also a test. Will the system learn? Will it change? Or will we be reading another article like this in six months, about another person who waited too long for help that never came?
The coroner has done her job. Shes identified the risk and issued the warning. Now its up to the people who hold the purse strings and write the policies to do theirs.
If you or someone you know is struggling with suicidal thoughts, please reach out. In the UK, you can call Samaritans free on 116 123, or contact NHS 111. Help is available. You dont have to wait alone.
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Mike Brown
Mike Brown – One of those authors who helps readers not get lost in today's news flow. He dives into political affairs as well as world events, social trends, and everyday stories that matter to everyone. The main focus of his work is fact-checking, clear language, and the ability to lay out the key points so that the reader gets a comprehensive and reliable picture of the topic in just a few minutes.
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