Source · Prevention of Future Deaths

Patrick Viles

Ref: 2025-0313 Date: 20 Jun 2025 Coroner: R Brittain Area: Inner North London Responses identified: 1 / 2 View PDF

A doctor prescribed medication to a patient with known suicidal ideation shortly after a psychologist recommended urgent psychiatric input, raising concerns about medication safety.

Date 20 Jun 2025
56-day deadline 15 Aug 2025
Responses identified 1 of 2
Alcohol, drug and medication related deaths Suicide (from 2015)

Coroner's concerns

AI summary
A doctor prescribed medication to a patient with known suicidal ideation shortly after a psychologist recommended urgent psychiatric input, raising concerns about medication safety.
View full coroner's concerns
The MATTERS OF CONCERN following the inquest into Mr Viles’ death were as follows:

1. I heard evidence from several medical professionals regarding the risks that Mr Viles posed to himself and that this risk was recognised prior to his death.

You provided a statement, dated 5/1/25, for the inquest which set out the interventions that you and your colleagues had undertaken to treat Mr Viles’ back pain in 2023 and 2024. No reference was made to any prescriptions that you issued and therefore, given the medical cause of death that had been proposed, I did not summons you to attend the inquest. You did note that you had referred Mr Viles to a psychologist, who consulted with him on 19/6/24 and raised concerns regarding the need for urgent psychiatric input, given his suicidal ideation. You also noted that you reviewed him after the psychologist’s input and concluded that he was not suitable for spinal cord stimulation.

At the inquest it could not be determined from where Mr Viles had obtained the medication on which he overdosed. I therefore wrote a letter of concern to you, asking if you had prescribed medication (as had been suggested by the mental health trust’s evidence).

You replied on 13/6/25, setting out that you had prescribed four weeks’ worth of on 28/6/24 (nine days after the psychologist’s consultation).

I am concerned that you prescribed this medication after the psychologist you had referred Mr Viles to had raised significant concerns regarding his mental health.

Responses

1 respondent
Complex Spine Clinic Other
24 Aug 2025 PDF
Noted

The Complex Spine Clinic confirms that no prescriptions were issued to the patient after receiving a letter from their psychologist suggesting a potential risk of suicide. (AI summary)

View full response
Dear Mr Brittain, Further to my letter on 13/06/2025, I confirm that I have not generated any prescription to this patient after receiving a letter from his psychologist suggesting the potential risk of suicide. I received the letter on 07/07/2024, and I have never seen the patient or prescribed the patient with any medication ever since. This is to confirm what I have written in my response letter on 13/06/2025 that clarifies there is no prescription made at all after knowing that the patient was at any suicidal risk. Hoping that this letter clarifies my situation with this patient and reassures you that I have not prescribed any medication to a patient at risk of suicide.

Report sections

Investigation and inquest
Mr Patrick Viles died on 15/7/24 at the age of 28 years. An investigation into his death was opened on 23/7/24. The inquest was concluded on 9/5/25.

I reached the conclusion that Mr Viles died from suicide.
Circumstances of the death
Mr Viles suffered from back pain, depression and insomnia. He was under the care of several doctors, including both NHS and private providers for these conditions.

He had suicidal ideation on several occasions and had previously overdosed on medication. He took a further intentional overdose of medication, including , and , at his home residence and died as a consequence of this act. I determined that he intended to end his life.

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Report details

Reference
2025-0313
Date of report
20 June 2025
Coroner
R Brittain
Coroner area
Inner North London

Responses identified

Responses identified 1 of 2
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 15 Aug 2025.

Sent to

Complex Spine Clinic
Princess Grace Hospital

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