There were failings in the care of former England cricketer Graham Thorpe in the months before he died, a coroner said as he recorded a conclusion of suicide.

Thorpe was not perceived by healthcare professionals to be in a “crisis situation” after they were told he had asked his wife “for help to end his life” weeks before he died, Surrey Coroner’s Court in Woking heard.

The 55-year-old, regarded as one of the best English players of his generation, died on 4 August 2024 after being struck by a train at Esher railway station in Surrey.

Coroner Jonathan Stevens said there had been “shortcomings” in Thorpe’s care, but they did not amount to gross misconduct.

The court heard Thorpe had “spiralled into depression” after losing his job as a batting coach, and had tried to take his own life on another occasion.

After he missed an appointment with the community mental health team on 28 June, care co-ordinator Katie Johnson spoke to his wife Amanda on the phone, who said her husband was “constantly asking for help to end his life”, the court heard.

Ms Johnson said she then spoke to Thorpe who told her he “hadn’t been out for a while” and “didn’t see the point of being here”, but had no immediate plans to act on suicidal thoughts.

The coroner said that the last time the cricketer had been seen in person by healthcare professionals was on 20 March.

“In my judgment, there were shortcomings in the care that should have been provided to Graham in the last four months or so of his life,” Mr Stevens said.

“If he had been seen in those last four months, particularly after that incident on 28 June, I cannot say whether it would or would not have made any difference.”

An investigation was carried out by Surrey and Borders Partnership NHS Foundation Trust after Thorpe’s death.

Dr Shriti Burgul, a consultant psychiatrist who reviewed the investigation’s report before it was finalised, told the court one of the findings was “it was noted Mr Thorpe’s presentation at his appointment on 28 June 2024 was in keeping with previous presentations and not perceived by the team as a crisis situation”.

Asked if arranging an appointment in two weeks was an appropriate response, Dr Burgul said that in the absence of a patient expressing “active intent” or an “active plan” it would be appropriate to allow two weeks.

She told the court that Thorpe was not at the level of requiring intervention from the home treatment team.

The psychiatrist was asked if there was any evidence that there would have been a different outcome if there had been an in-person assessment. She replied, “no”.

The investigation noted a letter from when Thorpe was discharged from a private hospital in July 2022, which said a neuropsychologist should be identified to provide further support, the inquest heard.

Given the conversation was over the phone, the psychiatrist was asked if it would have been appropriate to arrange to see Thorpe quickly.

She told the court: “In the wisdom of hindsight, then yes, a home visit would have been clinically indicated.”

This was never done by the private provider or the GP, and a risk panel advised it should be explored in June 2024, Dr Burgul told the court.

Asked whether there was any neuropsychological impact that could have affected the cricketer’s ability to engage in appointments, given he missed some, the psychiatrist said: “It’s a possibility, yes”.

Thorpe’s cause of death was recorded by a pathologist as multiple injuries, the coroner said.

His widow said the termination of his employment with the England and Wales Cricket Board had been a “real shock to Graham”, which was the “start of the decline of his mental health”.

Mrs Thorpe described her husband as her “best friend and soulmate”.

Following the conclusion of the inquest, she issued a statement that said: “We will never get over the tragic loss of Graham and we miss him everyday.

“Next Friday would’ve been Graham’s 56th birthday and we plan to celebrate his life at the Oval.”

Mrs Thorpe said the family would gather with the charity Mind to raise funds to help people affected by mental health illness.

“We would like to reduce the stigma and shame felt by sufferers, especially middle-aged men,” she added.

She said the event was to also raise awareness of people who are supporting families and friends living with mental health issues.

Thorpe was a left-handed batter who had played for Surrey County Cricket Club.

He was a mainstay in the England set-up for many years, first as a batter between 1993 and 2005, before spending 12 years in coaching roles.

During a distinguished international career, Thorpe struck 16 Test hundreds for England, including a debut century against Australia at Trent Bridge in 1993, and represented his country 182 times in all formats.

During his role with the England and Wales Cricket Board, he mentored players Ben Stokes and Joe Root.

The ECB described Mr Thorpe as “one of England’s greatest cricketers” and was a “deeply admired and much-loved person”.

A spokesperson for the board said: “His generosity, warmth, and passion for the game left a lasting impact on everyone fortunate enough to know him.

“His untimely death is a profound tragedy, and his loss is felt deeply across the cricketing community and far beyond.

“Our thoughts and heartfelt sympathies are with his wife, children, his father, and all those who loved him.”

They added Mr Thorpe’s passing was a “stark reminder” of the challenges many face with mental health.

“We hope the upcoming ‘Day for Thorpey’ at the Kia Oval will both honour his memory and encourage others to seek the help,” they said.

Additional reporting by PA Media.

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