That result showed she was suffering from moderately severe depression.

The assistant coroner continued: “I heard evidence from North Cheshire and Mersey NHS Foundation Trust that in 2024, the ADHD Service Halton had over 1,250 patients awaiting assessment.

“That was alongside high referral rates of around 100 plus per month.”

She went on to say the service was still experiencing “sustained high demand”.

“Over the last two years the service has experienced a 600% increase in referrals which was in line with ADHD services nationally.”

Murphy said Grove House Medical Practice requested an expedited assessment, but that it was rejected on the grounds of “insufficient evidence being provided within the form”.

Likewise, a lack of national NICE guidelines for the ADHD referral process would result in an inconsistent approach to assessments, the assistant coroner said.

She added waiting times varied across the country and patients did not know how long they would be expected to wait for an assessment.

Murphy concluded, saying: “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.”

The Department for Health and Social Care offered its “sincere condolences” to Hewitt’s family and loved ones, and said it had launched a review into the country’s ADHD services.

It said the results, which were due shortly, would “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 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” would be shared across the service to “help us to pay close attention to any emerging trends that may require further review and action”.