Lee Jay Bonsall · Prevention of Future Deaths report

On 6th March 2012 I commenced an investigation into the death of Lee Jay Bonsall then aged 23. The investigation concluded at the end of the inquest on 31st January 2014. The conclusion of the inquest was a narrative verdict namely that the deceased had suspended himself by a ligature from a bannister railing at his home address on 3rd March 2012 but the question of intent remains unclear. The medical cause of death was asphyxia by hanging.

(1) Mr Bonsall had joined the Army at the age of 17 and had served in Afghanistan. During his tour of Afghanistan he witnessed the death of a close friend.
(2) An army psychiatrist subsequently deemed Mr Bonsall temperamentally unsuitable for service. He was discharged from the Army in September 2007.
(3) Mr Bonsall continued to suffer from depression. He relocated to West Wales and registered with a surgery in 2010. After an assessment he was prescribed citalopram. He later renewed his prescription which his GP put on repeat prescription. This is contrary to good practice guidelines.
(4) His GP considered counselling as an alternative to citalopram but did not refer Mr Bonsall for psychotherapy as there was a ten month waiting list.
(5) Mr Bonsall was found hanging from a bannister rail at his home address by his wife on 3rd March 2012.

(1) That citalopram was given on repeat prescription which is contrary to guidelines. It may well be that awareness of these guidelines needs to be raised to ensure that GPs are aware that citalopram should not be given on
(2) The ten month waiting times for psychotherapy effectively means that this is not a viable alternative to anti-depressant medication and it might well be that a review of these waiting times is appropriate.