Robert Leighton SMITH · Prevention of Future Deaths report

On 29th October 2024 I commenced an investigation into the death of Robert Leighton SMITH. The investigation concluded at the end of the inquest on 10th March 2025. The conclusion of the inquest was Accidental death. The medical cause of death was 1a) Concomitant Dihydrocodeine and Pregabalin Toxicity.

On 25th October 2024, Robert Leighton Smith was found unresponsive at his home address, ████████ He was on high levels of prescribed painkillers for pain. He had a history of mental health difficulties and was on the waiting list for Interpersonal Psychotherapy (IPT). Police found no suspicious circumstances and no evidence of third party involvement in his death. A post mortem included toxicology. He was found to have above therapeutic levels of his prescribed medication in his system

The inquest was told that Mr Leighton –Smith had been assessed as someone who would gain a real benefit from IPT. However he had not started it at the time of his death due to a significant waiting list. This was caused by the demand for the service being far higher than the capacity. The evidence was that at the time of the inquest the waiting time for IPT was on average 12 months. This was due to the ongoing demand against commissioned capacity.
The inquest was also told that IPT was not an outlier in relation to its waiting time and that the backlog for all other therapy type services were at a similar level. The consequence of such prolonged waits was that people were having to wait a long time for mental health therapy support that they had been identified as requiring. The Trust GMMH indicated they provided the services they were commissioned to provide but unless the additional services were commissioned they could not increase their provision and waiting lists would remain high.