David Ian Hamilton · Prevention of Future Deaths report

On 13TH February 2017 I commenced an investigation into the death of David Ian Hamilton. The investigation concluded on the 1st June 2017 and the conclusion was one of suicide. The medical cause of death was 1a Aspiration pneumonia and gastrointestinal haemorrhage; 1b Drug toxicity (combined mirtazapine and paracetamol toxicity); II Ischaemic heart disease

David Ian Hamilton developed difficulties with his sleeping in October 2016. He sought help with his insomnia via A+E and via his GP. He self-referred to healthy minds for assistance. He was prescribed mirtazapine to assist. He attended group therapy sessions run by healthy minds. He became increasingly anxious and reported thoughts of self-harm both to his GP and at healthy minds group sessions. On the 7th February 2017, he was found dead at his home address. 10 Willow Wood Close, Ashton-under-Lyne.

1. Healthy Minds had no documentation or system of recording the selection process for therapy including the options given and rationale for the choice of therapy;
2. There was a lack of clarity of triggers for referrals other than group therapy;
3. The system of sharing information between health professionals (the GP and Healthy Minds) to identify if the correct services were being accessed or if a referral to a psychiatrist was required was limited and meant that those involved did not have a full picture of his mental health;
4. Referrals were not made to sleep clinic services to assist with insomnia
5. There was no evidence of a clear formal escalation process where concerns were held by a health professional