Source · Prevention of Future Deaths
Jonathan Thorpe
Ref: 2014-0006
Date: 8 Jan 2014
Coroner: John Pollard
Area: Manchester (South)
Responses identified: 0 / 1
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A GP failed to consult or refer a known self-harmer to Mental Health Services, prescribing medication without adequate assessment of his ongoing mental health needs.
Date
8 Jan 2014
56-day deadline
5 Mar 2014 est.
Responses identified
0 of 1
Coroner's concerns
A GP failed to consult or refer a known self-harmer to Mental Health Services, prescribing medication without adequate assessment of his ongoing mental health needs.
View full coroner's concerns
The deceased registered with your GP practice on the 20"h March 2013, was seen by on the 25th March and was issued a 'sick note' was prescribed Amitriptyline for depression (despite being a known self-harmer) . He was then seen on the 28" March by Iwhen a further 'sick note' was issued, this time back dated for one month. On neither of these consultations was there any reference to Mental Health Services, either for advice as to his previous involvement with them nor as to whether he needed further input from them;
Report sections
Investigation and inquest
On 10th May 2013 commenced an investigation into the death of Jonathan Alan (dob 25th September 1985). The investigation concluded at the end of the inquest on January 2014, The conclusion of the inquest was that the deceased took his own life. The medical cause of death was 1a Asphyxia secondary to Hanging_
Circumstances of the death
Following deteriorating family issues and whilst using various illicit drugs, the deceased went to a tree in a local cemetery and hanged himself from one of the tree branches.
Action should be taken
In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action:
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Report details
- Reference
- 2014-0006
- Date of report
- 8 January 2014
- Coroner
- John Pollard
- Coroner area
- Manchester (South)
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: 5 Mar 2014 (estimated).
Sent to
- King Street Medical Centre