Christopher John Stubbs · Prevention of Future Deaths report

On 30 July 2015 I opened an inquest into the death of Christopher John Stubbs who, at the date of his death, was aged 36 years old. The inquest was resumed and concluded on 20 February 2016
I found that the cause of death to be: -

1a. Hanging

I arrived at a conclusion of suicide.

On 26 July 2015 Christopher John Stubbs, who had a history of mental ill health and drug misuse and a previous attempt to take his own life by drug overdose on 7 February 2015, was found to be suspended from a ligature made from a bath robe cord attached to a door on the landing of his home address. It was found that he intended to take his own life.

During the course of the inquest I heard that Christopher’s prescribed medication of mirtazapine and pregabalin was stopped by the acute hospital doctors on his discharge from the hospital following his overdose of 7 February 2015, pending a further review by his GP, which I heard did not take place prior to his death.

• To review the effectiveness of existing office systems and procedures in relation to the receipt of discharge summaries from hospitals which advise on the review of patient’s medication.