Source · Prevention of Future Deaths
Christopher Stubbs
Ref: 2016-0081
Date: 3 Mar 2016
Coroner: Martin Fleming
Area: West Yorkshire (West)
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner identified concerns with the effectiveness of office systems for receiving hospital discharge summaries advising medication review, specifically that a GP review of Christopher's medication did not take place.
Date
3 Mar 2016
56-day deadline
28 Apr 2016 est.
estimated from the report date
Responses identified
0 of 1
Coroner's concerns
The coroner identified concerns with the effectiveness of office systems for receiving hospital discharge summaries advising medication review, specifically that a GP review of Christopher's medication did not take place.
View full coroner's concerns
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.
The MATTER OF CONCERN is as follows. –
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.
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.
The MATTER OF CONCERN is as follows. –
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.
Report sections
Investigation and inquest
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.
1a. Hanging
I arrived at a conclusion of suicide.
Circumstances of the death
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 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.
Copies sent to
I have sent a copy of this report toBradford District Care NHS Foundation TrustNHS EnglandChief Coroner DATED this 3rd March 2016M. D. Fleming Senior Coroner
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Report details
- Reference
- 2016-0081
- Date of report
- 3 March 2016
- Coroner
- Martin Fleming
- Coroner area
- West Yorkshire (West)
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 28 Apr 2016 (estimated from the report date).
Sent to
- Wibsey and Queensbury Medical Practice