Two-day inquest into the death of a man who had a history of drug and alcohol misuse and significant mental health difficulties. He attended hospital after having been found with significant quantities of recreational and prescription drugs and having expressed suicidal thoughts. He was discharged with no follow up and was found that evening having hanged himself in nearby woodland.

Issues explored at the inquest: (a) the adequacy of capacity assessments, discharge decisions and psychiatric assessments; and (b) causation. This case was one of five inquests being held as part of a multi-agency investigation into wider systemic issues found to have potentially caused or contributed to 11 deaths arising out of care provided at Derriford Hospital to patients with psychiatric / psychological needs. The Coroner’s conclusions may well lead to an overhaul in the general approach at this hospital to the treatment of patients with psychological / psychiatric disorders or symptoms who are experiencing crisis. See media here.