Daniel Norman Hatchett · Prevention of Future Deaths report

On the 6 January 2025 I commenced an investigation into the death of Daniel Norman Hatchett, aged 64 at the time of his death. The investigation concluded at the end of the inquest on 26 June 2025 with a conclusion of suicide.

Mr. Daniel Hatchett had no history of mental health diagnoses. In the last few years of his life he suffered a decline in his physical health (most notably due to dilated cardiomyopathy, chronic kidney disease and atrial fibrillation), which together with work stresses caused a decline in his mental health. He attended a holistic BUPA assessment in December 2023. The BUPA report highlighted stress levels and a new diagnosis of atrial fibrillation which required prompt attention. Both health concerns were reported to Mr. Hatchett's general practitioner. In response to the BUPA report, Mr. Hatchett's GP directed him to A&E to obtain urgent treatment for the atrial fibrillation. Treatment was provided by the A&E team in the form of anticoagulation. The GP surgery did not action the recommendation for primary care psychotherapy and/or follow-up of his mental health to address his levels of stress. Mr. Hatchett did not present to any of the healthcare professionals as being at risk of suicide or at risk of deliberate self-harm, but he was not expressly questioned about his mental health. There was a missed opportunity to refer him for therapy in January 2024 and/or for the GP to follow up on Mr. Hatchett's mental health. It is not possible to conclude on the balance of probabilities that this would have prevented his death in November 2024. In the very early hours of the 9 November 2024 Mr. Hatchett was discovered hanging in his home address. Paramedics attended and pronounced his life extinct on scene. Police attended, investigated and deemed the circumstances as non-suspicious.

1. Patients with chronic disease often present with concomitant mental health decline.
2. GP appointment timings are often insufficient for the necessary holistic review of this cohort of patients.
3. Templates for GPs, to assist them in reviewing patients with chronic disease, do not include a section for review of mental health. It was considered that such a requirement could assist in identifying patients whose mental health has been adversely affected by declining physical health. This would allow the opportunity for necessary mental health support to be offered to these patients.
4. The inquest heard that it is well known that middle aged men infrequently open up to their GP to express concerns about their mental health. An express question on a chronic disease review could help to elicit concerns that would otherwise remain undiscovered.