David Stables · Prevention of Future Deaths report

On 28 March 2024 I commenced an investigation into the death of David Stables. The investigation concluded at the end of the inquest on 4 December 2024. The conclusion of the inquest was

Suicide

1a Bilateral transection of the ulnar arteries

1b Incised wounds to the wrists

David Stables had a history of mental health issues and had taken two drug overdoses in 2020. He was prescribed sertraline in April 2020 and weaned himself off this in 2023. His last prescription was issued in July 2023.

David attended many appointments at his GP practice from 2020 to 2023 regarding other issues unrelated to his mental health. In most of these encounters there is no record of any discussions regarding his mental health. Whilst he received repeat prescriptions for his sertraline, there is no recorded entry of a review of his mental health or appropriateness of the medication. It is noted that he had reduced this himself yet there is no recorded entry of a full review of his mental health at this time.

I am concerned that there were no recorded mental health or medication reviews from April 2020 until February 2024 when David attended the GP asking for help. I was unable to establish whether these reviews had taken place and just not been recorded or whether full mental health reviews had not taken place when they should have been.

In February 2024 he attended the GP surgery and had a face to face appointment regarding his mental health. He had anxiety and had difficulties in sleeping and poor appetite. A shared decision was undertaken to put David on mirtazapine at 15mg and to follow up in 4 weeks time. I was informed that this was considered because of its side effects of sedation and increased appetite. A full mental state examination was undertaken which did not identify any Self harm or suicidal concerns.

On 18 March 2024 he was seen again by the GP and there was some improvement. I was told that self harm and suicidal ideation were specifically discussed and they were strongly denied at both appointments.

There was no concern from the GP when he called 2 days later to ask for an increase his medication although it was accepted that had she known he had tried to contact the GP surgery on 5th 14 and 15th March then this may have changed her management in terms of obtaining more information either by reception or by another appointment. However, I do find that whilst he may have attempted to contact the GP it cannot be ascertained if these calls actually made it through to the reception team. I find that there is no evidence to say that this would have changed the management in terms of the medication although it may have been considered. Further there is evidence that even if medication had been increased it could have taken up to 4 - 6 weeks to show any benefit.

David had been given all relevant safety netting advice for a crisis and this was provided verbally and by text message.

(1) I am concerned that there were no recorded mental health or medication reviews from April 2020 until February 2024 when David attended the GP asking for help. I was unable to establish whether these reviews had taken place and just not been recorded or whether full mental health reviews had not taken place when they should have been.

(2)

(3)