Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0234, written 17 May 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 May 2025 |
|---|---|
| Reference | 2025-0234 |
| Deceased | Joseph Powell |
| Coroner | Sarah Murphy |
| Coroner area | Cheshire |
| Category | Suicide (from 2015) · Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: The Royal College of General Practitioners (RCGP), 30 Euston Square, London, NW1 2FB 1 CORONER I am Sarah Murphy, Assistant Coroner for the coroner area of Cheshire. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 09 September 2024 I commenced an investigation into the death of Joseph David POWELL aged 28. The investigation concluded at the end of the inquest on 13 May 2025. The conclusion of the inquest was: Suicide against a background of post-traumatic stress disorder and depression. The medical cause of death was: 1A Hanging 2 Post traumatic stress disorder and depression. 4 CIRCUMSTANCES OF THE DEATH The deceased was 28 years of age with a medical history of mental illness. In March 2024 he was diagnosed with depression and was prescribed Sertraline for 28 days. He did not receive a further prescription for this as he had not booked a follow up appointment with his GP as requested. On the 22 August 2024, he re-presented to his GP surgery and was diagnosed with post traumatic stress disorder and an exacerbation of his depression. He denied any active suicidal thoughts but had experienced suicidal ideation. He was prescribed Citalopram, and provided with a telephone number for a local psychotherapy service and agreed to make a follow up appointment for a review with the GP in one to two weeks’ time. He did not subsequently book a review appointment with his GP. On the 6th September 2024, he was found at his home address suspended . He was cut down and cardiopulmonary resuscitation was commenced whilst waiting for paramedics to arrive. He did not respond to resuscitation and death was certified on the scene by paramedics at 21:24 hours. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: 1) That not all GPs book follow up appointments for patients presenting with mental health difficulties such as depression, anxiety and post-traumatic stress disorder. Regulation 28 – After Inquest Document Template Updated 30/07/2021 Instead, they request that the patient book their own follow up appointment with their GP. This can be difficult for patients who are suffering with mental health difficulties and can result in patients not receiving a follow up appointment with their GP or any further medication. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by July 14, 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to Family of Joseph Powell Counsel for the GP surgery. who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated 17 May 2025 Ms Sarah Murphy HM Assistant Coroner for Cheshire. Regulation 28 – After Inquest Document Template Updated 30/07/2021
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Ms Sarah Murphy Assistant Coroner – Cheshire Sent by email to: Dear Ms Murphy 09 July 2025 Regulation 28 Report to Prevent Future Deaths - touching on the death of Joseph David Powell I was sorry to hear of the tragic death of Mr Powell and our condolences go to his family. The Royal College of General Practitioners works to improve patient care by encouraging the highest possible standards in general medical practice by supporting members, setting standards, providing education and training promoting research and advocating and representing the College. We understand that Mr Powell was diagnosed with Depression in March 2024 and did not follow up with a GP after receiving a prescription for Sertraline until the 22 August 2024. He re-presented with additional symptoms of PTSD and after a different prescription of antidepressants he failed to rebook another appointment and was found hanging on the 6 September 2024 and subsequently died. Your matter of concern for which you have asked for comment is ‘That not all GPs book follow up appointments for patients presenting with mental health difficulties such as depression, anxiety and post-traumatic stress disorder. Instead, they request that the patient book their own follow up appointment with their GP. This can be difficult for patients who are suffering with mental health difficulties and can result in patients not receiving a follow up appointment with their GP or any further medication.’ The management of Mental Health conditions is a fundamental area of General Practice and covered by the GP Core Curriculum in the Clinical Topic Guide for Mental Health . The College also supports member with continuing professional development by publishing a range of learning materials which are collated in the mental health toolkit . There is a specific section on crisis, self-harm and suicide as well as an e-learning course on suicide prevention, available to all members. Royal College of General Practitioners 30 Euston Square, London, NW1 2FB Tel: 020 3188 7400 | info@rcgp.org.uk | rcgp.org.uk Registered Charity Number 223106 | Patron: His Majesty King Charles III The area of follow up is an important one to be considered by the GP when understanding the risks to the patient and it is important to consider this in the consultation together with the patient and to build a safety netting approach. This is done through a personalised and shared care approach, including consideration of the individual’s needs, a management plan and follow up arrangements. As part of the management plan there would often be a safety plan for those identified as at risk of suicide which would include specific follow up arrangements. These follow up arrangements could include rebooking of GP follow up using the surgery processes or through the GP booking the follow up dependant on individual circumstances. Depression is a common condition and often also associated with other mental health conditions and recognition of suicide risk is a part of the GP consultation. The management plan would include a specific safety plan which could include support for booking appointments and further planning if patients do not attend appointments. The RCGP actively promotes ongoing professional development for its members, and it has a Mental Health Special Interest Group (SIG). As a College our action shall be to highlight this case to the Mental Health SIG to support further promotion of safety planning in suicide prevention for people with mental health conditions and to consider GP booking of appointments where this is a part of the safety plan. Once again, we were sorry to hear about this tragic death and offer our condolences to his family. Yours sincerely Honorary Secretary
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