Coroner concerned about man’s death

A CORONER has raised concerns over the death of a man after a local GP failed to record reviews of his mental health or medication and said there is a risk of future deaths if measures are not taken.

David Stables had a history of mental health issues and suffered two drug overdoses in 2020.

He was then prescribed sertraline, a type of antidepressant, in April 2020, and weaned off it in 2023.

David’s last prescription was issued to him in July 2023.

However, a report, which was sent to the chief coroner, shows there was no record of any mental health support being given to David by his GP Dearne Valley Practice, based in Thurnscoe.

The report said: “David attended numerous appointments at his GP practice from 2020 to 2023 regarding other issues unrelated to his mental health.

“In most of these encounters, there is no record of discussions regarding his mental health.

“Although he received repeated prescriptions for his sertraline, there is little documentation of a review of his mental health or the appropriateness of the medication.

“I am concerned that no mental health or medication reviews were recorded between April 2020 and February 2024, when David went to the GP seeking help.

“In February 2024, he attended the GP and had a face-to-face appointment regarding his mental health.

“He suffered from anxiety, had difficulty sleeping and a lack of appetite.”

A decision was then made to put David on mirtazapine, another antidepressant at 15 mg, and follow up in four weeks.

The report added: “On March 18, 2024, he was seen again by the GP and there was some improvement.

“I was told that self-harm and suicidal thoughts were specifically discussed and strongly denied at both appointments.

“The GP had no concerns when he called two days later to ask to increase his medication, although it was accepted that had she known he had tried to contact the GP surgery, that could have

changed his management in terms of obtaining more information either through reception or through another appointment.

“However, I note that although he attempted to contact the GP, it is not possible to know whether these calls were actually passed on to the reception team.”

Marilyn Whittle, deputy coroner for South Yorkshire West, opened an inquest into David’s death on March 28.

The investigation ended earlier this month.

She said: “During the investigation, the evidence revealed some concerning matters.

“In my opinion, there is a risk of future deaths if action is not taken.

“I am concerned that no mental health or medication reviews were recorded between April 2020 and February 2024, when David went to the GP seeking help.

“I have not been able to determine whether these examinations had taken place and were simply not recorded or whether full mental health examinations had not taken place when they should have been .

“In my view, steps should be taken to prevent future deaths and I believe Dearne Valley Practice has the authority to take such steps.”

Dearne Valley Practice now has until January 31 to respond to the report.

A spokesperson said: “We are truly sorry for the death of Mr Stables and extend our sincere sympathies to his friends and family.

“We have noted the coroner’s report and will respond to it within the allotted time frame.

“We cannot comment further due to our duty of confidentiality to patients.”