Narjit Gill · Prevention of Future Deaths report

On 12 May 2023 I commenced an investigation into the death of Narjit Gill, aged 61 years. The investigation concluded at the end of the inquest on 9 February 2024. The conclusion of the inquest was suicide, with the medical cause of death confirmed as hanging.

1. Mr Narjit Gill died on 5 May 2023, by hanging himself ████████
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2. He had recently been in contact with mental health services, following reports to police from his friend, that he had attempted suicide. Mr Gill received a number of telephone calls, home visits and face to face appointments, commencing 24 April 2023 until his death.
3. Mr Gill was seen at his home by registered mental health practitioners, on 3 May 2023. During this visit, he disclosed that he continued to experience suicidal thoughts “on an almost constant basis”, and he reported that he had attempted to ligate himself from a tree in the garden on a number of occasions and had also made an attempt to ligate from a stair rail within his home.
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5. Mr Gill continued to express suicidal ideation, although he agreed to engage with Mental Health services, to attend all appointments and to take anti-depressant medication.
6. A home visit by the same mental health practitioners, was arranged for Mr Gill on 5 May 2023. Sadly, upon their arrival, Mr Gill was found to have ended his life by hanging himself ████████.

(1) Failure to remove ████████ when it was seen on 3 May 2023 by mental health practitioners who visited Mr Gill at his home, in light of his continued expression of suicidal ideation.