Mr George Arthur Cheese · Prevention of Future Deaths report

I conducted an Inquest into the death of Mr George Arthur Cheese that was heard at Reading Town Hall between the 23rd and 25th May 2017 inclusive. The conclusion of the Inquest was that Mr Cheese took his own life whilst suffering from a depressive disorder brought on by a series of life events. A full copy of the Narrative Conclusion is attached.

Mr Cheese was an 18 year old young man who was found hanging in Woodland near his home address on 9th April 2015. He had a number of ongoing issues in his life including the potential loss of a career in the army; a fluctuating relationship with his girlfriend; an unsubstantiated concern that he might have a serious illness and he had been subject to upsetting treatment by his colleagues at work. He was under the care of his GP surgery and the local Mental Health Team who were treating him for anxiety and depression including prescribing anti-depressant medication.

(1) While the evidence at the Inquest dealt with the various matters ongoing in Mr Cheese’s life, I also heard evidence of the care and treatment that he received from his GP surgery. One of the doctors at the surgery, ████████
████████ gave live evidence at the Inquest.

(2) Mr Cheese was prescribed Fluoxetine anti-depressant medication on the 3rd November 2014 by a treating GP, following admitting to fleeting suicidal thoughts. He was reviewed by ████████ on 14th January 2015 when Mr Cheese described daily episodes of intense low mood with suicidal thoughts which included taking an overdose. This led to a reference to the Mental Health Team. At an appointment with the Practice’s Nurse Practitioner on 3rd February, Mr Cheese was prescribed 112 tablets of Fluoxetine. In the course of her evidence, ████████ stated that the Nurse Practitioner was probably just repeating the same prescription that the previous Doctor had issued to Mr Cheese but that she, ████████, would not have done that.

(3) ████████ also acknowledged, in the course of her evidence, that there was no “flag” on Mr Cheese’s notes to alert treating Clinicians within the GP Practice to limit the amount of medication provided to Mr Cheese in view of his history. She acknowledged that a flag, in such circumstances, was good practice.

(4) The concerns arising from the evidence are therefore the amount of medication prescribed to a patient who was known to be suffering from mental health issues and describing suicidal thoughts and a potential overdose and the fact that this was not being flagged to prevent large amounts of medication being provided to him as a matter of repeat prescription.