Barry Marshall Fullarton · Prevention of Future Deaths report

On 20/12/2018 I commenced an investigation into the death of Barry Marshall Fullarton aged 79. The investigation concluded at the end of the inquest on 17 May 2019. The conclusion of the inquest was:

Barry Marshall Fullerton died by Suicide, when suffering from a reactive depressive illness, which affected his mood in the morning.
The Cause of death was:

I a Multiple injuries
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On the 17th December 2018 at 9.05 Barry Marshall Fullerton was certified as having died beneath the balcony of his bedroom at ████████, West Kirby. There was a chair placed on the balcony above. It is found that he used this intentionally to fall over the balcony with fatal intent. In October 2018, Mr Fullarton had suffered a stroke which was more likely than not the cause of a reactive depressive illness which included a significant diurnal variation in mood (low mood in the morning and normal affect in the afternoon). The depressive illness manifested in thoughts of intentional self-harm and suicide. On the 14th December 2018, Barry Fullerton underwent a mental health assessment. This took place in an afternoon and he was assessed as being safe to go home. He was on anti-depressant medication (found present in post-mortem toxicology) but he had declined to engage in an assessment of appropriate psychological therapy plan. It is unclear as to whether a mental health assessment in a morning would have assessed different needs.

Those carrying out mental health assessments should have regard to how a mental disorder manifests in a patient. In this case, the diurnal nature of the reactive depressive illness was evident from the medial records such that an assessor could have documented that the assessment at a particular time when mood was good may not be valid when in low mood.