David John Ireland · Prevention of Future Deaths report

On 21st February 2017 I commenced an investigation into the death of David John Ireland. The investigation concluded at the end of the inquest on 6th February 2018. The conclusion of the inquest was

Multiple Traumatic Injuries

Conclusion – Accidental Death

David experienced an episode of acute onset psychosis and exhibited bizarre behaviour. He forced entry into a house on St James Road, Exeter and when detained in a first-floor bedroom by the residents, climbed out of the window and fell to the ground sustaining serious injuries. He died in Royal Devon and Exeter Hospital shortly after admission on 13 February 2017.

(1) Contact was made by Mr Ireland’s friend on the day of his death with the crisis team. Mr Ireland also spoke with them during the same telephone contact call. No advice was given that Mr Ireland could present at the emergency department should concerns continue about his mental health crisis.

Had such advice been given it may have impacted on the course of events and facilitated an urgent mental health assessment. This opportunity was lost as Mr Ireland was not able to make any such decision and his friend was unaware that this was an option available with sudden onset mental health symptoms.