Nicholas Alan Gray · Prevention of Future Deaths report

On 1 August 2025 an investigation was commenced into the death of Nicholas Alan GRAY, AGE 63. The investigation concluded at the end of the inquest on 5 June 2025. The conclusion of the inquest was 1a ████████ Toxicity

Suicide: Mr Gray took an overdose of ████████ with the intention to end his life. Mr Gray was discharged home in the absence of a psychiatric review or recommended mental health risk assessment.

Nicholas Alan Gray died at home on 24 July 2023 of ████████ Toxicity. Mr Gray had a history of suicidal thoughts and anxiety with low mood and depression contributed to by an exacerbation of pain of a chronic spinal condition with recent surgery. Mr Gray was receiving pain management and commenced an on antidepressant on 12 June 2023. Mr Gray made attempts to stab himself on 18 June 2023 with the intention to end his life and was seen by paramedics and the primary mental health team. Whilst en-route to hospital Mr Gray wished to go home, and an ECG raised concerns about an underlying cardiac issue. Further advice from primary mental health was that Mr Gray had capacity and therefore was taken home. No plan was put in place for assessment of Mr Gray’s mental health or risk to himself. On 22 June 2023 Mr Gray informed district nurses that he was going to end his life, this was escalated to his GP who contacted the mental health crisis team. Mr Gray was conveyed to hospital. On 23 June district nurses updated the acute trust nurse that Mr Gray had been at home, had attempted to hang himself, were concerned about Mr Gray’s safety at home and asked that he have a mental health assessment prior to discharge. Mr Gray was reviewed by and closed to mental health services on 24 June with no further action. Mr Gray was not referred to the psychiatrist during his 3-week admission and not reviewed by mental health services prior to discharge. Mr Gray received treatment for his physical healthcare and alcohol withdrawal and discharged on 17 July 2023.

(1) The Trust PSIRF Decision Monitoring Tool completed after Mr Gray died contained inaccurate information, the dates of EPUT contact and the substance of the interactions were inaccurate:

a. Self-harm was noted as “none known or recorded”
b. There was no record of the mental health liaison nurse review on 24 June 2023 and the discharge of Mr Gray from EPUT.

The information used to inform a potential investigation requirement contained significant omissions and was not consistent with the information known to the Trust.