David Morley Sargeant · Prevention of Future Deaths report

On 22nd June 2017 I commenced an investigation into the death of 48 year old David Morley Sargeant. The investigation concluded at the end of the inquest on 18th October 2018. The conclusion of the inquest was as follows;

David Morley Sargeant died on 16th June 2017 at The Ford, Mawgan, Helston, Cornwall, from the toxic effects of an intentional overdose of prescribed and controlled drugs.

My conclusion as to the death is that it was Suicide.

The medical cause of death was established on the evidence as:
1a) disease or condition directly leading to death - Mixed drug toxicity
II) other significant condition(s) which could have contributed to the death but are not related to the disease or condition causing it – suspension by ligature around the neck.

David Sargeant (known to family and friends as Davy) was found deceased in a car in a rural location following an intentional overdose. The doors were locked, the only set of keys were inside the vehicle. Davy had a ligature around his neck which the pathologist considered as secondary measure taken by Davy as part of his intention to kill himself.

Davy had a history of drug abuse. Davy had received treatment from the Cornwall drug addiction treatment service, Addiction. Davy displayed a historical pattern of chaotic illicit substance misuse. These periods were usually followed by periods of treatment and stabilisation, which included substitute prescribing and/ or rehabilitation. The Addaction report stated that during these more stable periods in his life he appeared to become more vulnerable to his ‘ADHD and mental health’.

In October 2016 Davy was referred by his GP to the community mental health team (CMHT), part of Cornwall Partnership NHS Foundation Trust (CPT) for assessment of possible ‘Attention deficit hyperactivity disorder’ (ADHD) which is a group of behavioural symptoms that include inattentiveness, hyperactivity and impulsiveness.

Davy was assessed in December 2016 by CMHT. However, Davy was discharged from CMHT without further diagnosis and treatment. This was because of the following reasons;-

1) CPT is not commissioned to assess, diagnose or treat adult ADHD.

2) Addaction Cornwall does not have access to a specialist psychiatrist with the skills to diagnose or treat ADHD.

3) Although the GP had the option to refer under Patient Choice for treatment out of county, the GPs previous experience indicated that this was impracticable because it would not be possible to successfully deliver the ongoing oversight and review of medication.

In summary, Davy could not be diagnosed and treated by specialist services either in Cornwall or out of county.