Jake Harvey READ · Prevention of Future Deaths report

On 7th May 2025 I commenced an investigation into the death of Jake Harvey READ aged 29. The investigation concluded at the end of the inquest on 26th May 2026.

The conclusion of the inquest was that of:

Suicide

The medical cause of death was confirmed as:

1a Exsanguination
1b Multiple Self Inflicted Knife Injuries

Jake Read was declared deceased at 14:42 on the 5th May 2025, at his home address in Melton, Suffolk.

When found, a large quantity of blood was seen in his bathroom, and a ████████ knife was found on the floor.

A subsequent postmortem identified that Jake had lacerations ████████ which by their nature were self-inflicted.

Toxicology analysis on blood samples taken from Jake identified that at the time of his death, Jake had no alcohol or any other drugs in his system.

On the 3rd May 2025 Jake had attended the Emergency Department of the Ipswich Hospital, requesting support with his Mental Health. Jake was described as being in an agitated state.

It was planned to prescribe Jake with a dose of Diazepam after his clinical observations were taken to check there was no contraindication to the dose being given. Following the dose of Diazepam the Mental Health Team planned to speak to him again once he was less agitated.

Jake left the Emergency Department prior to being given this medication, and at some later point returned home where he then inflicted knife wounds upon himself.

In undertaking the actions that he did on or before the 5th May 2025, Jake must have intended his own death, on a background of failing mental health.

My primary concern in Jake's case is that evidence heard that there is no national guidance or timelines in place for the administration of medication required in cases where an individual has been identified as being in a state of Mental Health agitation or Mental Health crisis.

On the 3rd May 2025 Jake arrived at the Emergency Department of the Ipswich Hospital at 16:36.

Jake was identified as requiring a consultation with the Mental Health Liaison Team at 17:05.

Two staff from the Mental Health Liaison Team first met Jake at 17:30.

At approximately 18:20-1830 it was identified that Jake required a dose of Diazepam to calm his agitation, to allow for a more effective Mental Health Assessment.

Prior to administration of the Diazepam clinical observations were required and these were being completed at 18:35. The observations showed no contraindications for the administration of Diazepam.

However, the Diazepam was not prescribed to Jake until 21:19, some 2 hours and 44 minutes after the clinical observations had shown no contraindications for the administration of Diazepam.

It is believed that Jake had left the Emergency Department at some time between 19:00 and 19:30.

It was not possible to identify on the available evidence whether the administration of Diazepam to Jake on the 3rd May would have prevented his death. However, it was acknowledged that there was a chance that had the Diazepam been administered, it might have changed the tragic sequence of events leading to Jake's death.

Evidence heard that in some medical cases clinical staff are given a clear timeline in guidance as to when it is expected a required medication is to be administered (sepsis being cited as an example). The court was told that no such guidance exists for the administration of drugs in Mental Health cases.

In Jake's case clinical staff stated that had such a timeline been in place, this would have prompted staff to prescribe and administer the necessary drug earlier than it was.

My second concern is that at the time of Jake's attendance on 3rd May 2025, one of the Mental Health Liaison Team staff who spoke to Jake at 17:30 was a qualified Non-Medical Prescriber, who could have prescribed the Diazepam to Jake herself.

However, at that time, even though a Mental Health Liaison Team Non-Medical Prescriber had assessed Jake required an immediate dose of Diazepam, this clinician had no direct access to the required drug.

Therefore, at that time, the Non-Medical Prescriber had to request an Emergency Department clinician to prescribe it for them. In Jake's case this caused the 2 hours and 44-minute delay between clinical observations being completed and drug prescription being made.

Evidence was heard that the East Suffolk and North Essex NHS Trust and the Norfolk and Suffolk Foundation Trust have changed the system at the Ipswich Hospital, and now the Mental Health Liaison Team Non-Medical Prescribers are able to both prescribe and access prescription medications within the Emergency Department, without the need to request an Emergency Department clinician to prescribe it for them.

When asked, the witness providing this evidence could not say whether the same provision was available in hospitals other than those covered by the relevant trusts.

As such, it is not known if direct access to Mental Health medication by Mental Health clinicians working in an Emergency Department is just a local arrangement, or if it is replicated in other jurisdictions?