Stephen Ratcliffe · Prevention of Future Deaths report

On the 20th February 2023, I commenced an investigation into the death of Stephen Ratcliffe, date of birth 6th October 1968 who died on the 6th February 2023 at his home address ████████
████████. The medical cause of his death was confirmed as 1a) Respiratory Depression due to 1b) Combined Drug Toxicity 2) Developing Liver Cirrhosis and Anxiety and Depression.

Stephen had a history of illicit drug and alcohol use. Had also had a diagnosis of depression and anxiety. He was under the local drug and alcohol services and for 11 months had been abstinent. He engaged well with his GP.

In November 2022 he relapsed and in December 2022 was expressing suicidal thoughts. On the 10th January 2023 he collected his weekly methadone prescription. This was the last contact anyone is known to have had with Mr Ratcliffe until he was found deceased on the 6th February 2023. He had not collected his subsequent prescriptions.

During the course of the Inquest the court heard evidence that enquiries were also being made of his physical health in particular the need for him to have a blood test HBAC1 to check for diabetes. Due to difficult venous access these blood tests were not done.

1. The court heard that due to the deceased having compromised venous access as a result of his drug use, the GP practice were unable to take his bloods. The evidence before the court was that there is no specialist service for GPs to refer a patient to for bloods when venous access is difficult. Evidence was heard that this had been raised previously to the CCG. As a result, in this case no test for diabetes was obtained.