David Joyce · Prevention of Future Deaths report

A coronial investigation was commenced on 1st September 2023 into the death of David Paul Joyce, aged 33, who had been found deceased on 31st August 2023 at his home address of 52 King Arthur’s Road, Exeter, having ligatured ████████ The investigation concluded at the end of the inquest on 17th June 2026. The medical cause of death was recorded as 1a) asphyxia due to hanging and the conclusion was suicide.

David Joyce had a history of mental health difficulties. In 2018 a psychiatric review diagnosed that David was having an acute dissociative episode and he was prescribed Quetiapine. In the summer of 2023, having had a period of some stability, his mental health deteriorated following the breakdown of a relationship, and he was experiencing feelings of low mood and having difficulty sleeping. He initially consulted the GP about this on 16th May and was encouraged to go back to work and get out of the house.

In June 2023, David was arrested having taken an overdose of paracetamol and caused damage to his room; he was seen by the Criminal Justice Liaison & Diversion Team in custody and was referred for support and advised to contact his GP. He approached his GP and disclosed that he had not been taking his Quetiapine since he’d moved to Exeter some years previously, and that he considered his most pressing symptom now was depression rather than anger. The GP issued a prescription for Quetiapine, seemingly with no consideration of a referral to mental health services, or any request for specialist psychiatric input regarding appropriate medication.
On 22nd August, David was found in a local wood ████████ He was encouraged down and detained under the Mental Health Act. A mental health assessment was conducted; David was referred to the Home Treatment Team and was seen by them on a number of occasions during which rapport was built and a plan for care going forward considered. David consulted with his GP again on 24th August and requested an urgent medication review. The GP advised that it would not be appropriate for her to make changes to his medication given that he was under the support of the Home Treatment Team, and, in evidence, said she thought the medication review would be undertaken by them. No medical review was conducted until 31st August, at which point alternative medication was prescribed, which was considered more appropriate to David’s symptoms. Later that evening, David was found dead at his home address of 52 King Arthur’s Road, Exeter, having suspended himself ████████ He had written a note to his family which was found ████████

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;
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.
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.