Lester John STACEY · Prevention of Future Deaths report

On 25.10.2016 I commenced an investigation into the death of Lester John STACEY. The investigation concluded at the end of the inquest on 9.3.2017. The conclusion of the inquest was Suicide the cause of death was hanging.

The deceased had a history of hypertrophic cardiomyopathy and mental health issues. He had been diagnosed with bi-polar affective disorder. He had contact with mental health services from 2005 to 2014 and was re-referred in May 2016. He received some in-patient care but on discharge he failed to engage with community services and was subsequently discharged. His medication was changed at this time. He had recently had some worries regarding his business and had been suffering with low moods. At about 1800 hours on the 23rd October 2016 he was found hanging in a barn at his home address, The Oaks, Green Lane, Eccleshall. He was certified dead at the scene. There was no third party involvement.

The deceased was admitted as an In-patient under S2 Mental Health Act from 16 May 2016 to 19 May 2016. He was discharged without being given follow up appointments. He subsequently failed to respond to telephone calls and letters to attend appointments. He was therefore discharged from the service on the 21 June 2016.

There was no attempt to visit him during this period to try and re-engage him with services. He may not have received the correspondence inviting him for appointments because he was away on holiday for some of that period. He might have benefitted from having pre-arranged appointments prior to his discharge. His medication was changed during his last admission and thereafter does not appear to have been monitored. The deceased was said to have lacked confidence in the new medication and may not have been totally compliant. Family perception was that he responded less well to the changed medication.