Concerns raised 5 Failure to seek specialist guidance on medication appropriateness in complex mental health presentations View source Failure to provide routine follow-up after mental health consultation View source Delays in amending medication when presenting symptoms indicate a different treatment View source Failure to initiate follow-up after presentation with deteriorating mental health View source Failure to consider referral to secondary or tertiary mental health services View source See 2 more concerns
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AI-generated summary
David Joyce · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Joyce, who had a history of mental health difficulties, died by suicide at his home on 31 August 2023 after being found having suspended himself. The concerns included a lack of follow-up and consideration of mental health referral after he first sought help, prescribing Quetiapine without specialist input despite his reported symptoms and overdose, and a delay of 15 weeks before a medication review led to a change in treatment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Foxhayes Surgery GP Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to seek specialist guidance on medication appropriateness in complex mental health presentations
Wider context from the report “2. David presented to the GP surgery again on 26th June. He reported that he’d had a ‘severe mental breakdown due to ongoing psychosis’ which had resulted in him taking an overdose and being arrested for being in possession of a weapon, and he’d been advised by Police mental health services to contact his GP for support. When he spoke to the GP, David informed her that he considered his most significant issue currently was depression, and said that he had not taken Quetiapine since he moved to Exeter some years previously. Despite the fact that David indicated depression to be his overriding concern, he had taken an overdose which resulted in hospital attendance, and he’d not taken Quetiapine for some time (and seemingly for different symptoms), the GP prescribed Quetiapine, without seeking guidance or input from a psychiatrist or mental health professional about whether that was an appropriate medication in the circumstances . No routine follow up appears to have taken place following that consultation. The next communication does not occur until the GP is informed that there had been a further suicide attempt resulting in a Mental Health Act Assessment of David on 22nd August.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Foxhayes Surgery GP Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to provide routine follow-up after mental health consultation
Wider context from the report “2. David presented to the GP surgery again on 26th June. He reported that he’d had a ‘severe mental breakdown due to ongoing psychosis’ which had resulted in him taking an overdose and being arrested for being in possession of a weapon, and he’d been advised by Police mental health services to contact his GP for support. When he spoke to the GP, David informed her that he considered his most significant issue currently was depression, and said that he had not taken Quetiapine since he moved to Exeter some years previously. Despite the fact that David indicated depression to be his overriding concern, he had taken an overdose which resulted in hospital attendance, and he’d not taken Quetiapine for some time (and seemingly for different symptoms), the GP prescribed Quetiapine, without seeking guidance or input from a psychiatrist or mental health professional about whether that was an appropriate medication in the circumstances. No routine follow up appears to have taken place following that consultation . The next communication does not occur until the GP is informed that there had been a further suicide attempt resulting in a Mental Health Act Assessment of David on 22nd August.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Foxhayes Surgery GP Practice; that does not assign responsibility.
PFD Monitor interpretation Delays in amending medication when presenting symptoms indicate a different treatment
Wider context from the report “3. On 31st August 2023, when a medication review was conducted, it was established that David needed a different medication given his presenting symptoms. This medication amendment therefore did not take place until 15 weeks after David had initially sought help from the GP .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Foxhayes Surgery GP Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to initiate follow-up after presentation with deteriorating mental health
Wider context from the report “1. David first presented to the GP surgery on 16th May 2023, reporting a deterioration in his mental health. No follow up was initiated by the surgery despite David’s recorded past medical history of dissociated disorder, self-harm and suicide. There was no evidence that, on that occasion, there had been any consideration of referral to secondary or tertiary mental health services which may have been available to assist David and inform his care;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Foxhayes Surgery GP Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to consider referral to secondary or tertiary mental health services
Wider context from the report “1. David first presented to the GP surgery on 16th May 2023, reporting a deterioration in his mental health. No follow up was initiated by the surgery despite David’s recorded past medical history of dissociated disorder, self-harm and suicide. There was no evidence that, on that occasion, there had been any consideration of referral to secondary or tertiary mental health services which may have been available to assist David and inform his care;
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations