Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0295, written 25 Jun 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Jun 2026 |
|---|---|
| Reference | 2026-0295 |
| Deceased | David Joyce |
| Coroner | Alison Longhorn |
| Coroner area | Devon, Plymouth and Torbay |
| Source | judiciary.uk record |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REPORT TO PREVENT FUTURE DEATHS REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 1. CORONER I am Alison LONGHORN, Area Coroner, for the County of Devon, Plymouth & Torbay. 2. DATE OF REPORT 25th June 2026 3. 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. THIS REPORT IS BEING SENT TO 1. The Foxhayes Surgery GP Practice You are under a duty to respond to this report within 56 days of the date of this report, namely by the 20th August 2026. I, the coroner, may extend the period if an appropriate application is made. 4. YOUR RESPONSE 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. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports - Courts and Tribunals Judiciary. 6. ACTION SHOULD BE TAKEN In my opinion, unless action is taken to address the concerns below, then there is a significant risk of future deaths, and I believe you have the power to take such action. 7. INVESTIGATION AND INQUEST A coronial investigation was commenced on 1st September 2023 into the death of David Paul Joyce, aged 33, who had been found deceased on 31st August 2023 at his home address of 52 King Arthur’s Road, Exeter, having ligatured . The investigation concluded at the end of the inquest on 17th June 2026. The medical cause of death was recorded as 1a) asphyxia due to hanging and the conclusion was suicide. 8. CIRCUMSTANCES OF DEATH David Joyce had a history of mental health difficulties. In 2018 a psychiatric review diagnosed that David was having an acute dissociative episode and he was prescribed Quetiapine. In the summer of 2023, having had a period of some stability, his mental health deteriorated following the breakdown of a relationship, and he was experiencing feelings of low mood and having difficulty sleeping. He initially consulted the GP about this on 16th May and was encouraged to go back to work and get out of the house. 2 In June 2023, David was arrested having taken an overdose of paracetamol and caused damage to his room; he was seen by the Criminal Justice Liaison & Diversion Team in custody and was referred for support and advised to contact his GP. He approached his GP and disclosed that he had not been taking his Quetiapine since he’d moved to Exeter some years previously, and that he considered his most pressing symptom now was depression rather than anger. The GP issued a prescription for Quetiapine, seemingly with no consideration of a referral to mental health services, or any request for specialist psychiatric input regarding appropriate medication. On 22nd August, David was found in a local wood was encouraged down and detained under the Mental Health Act. A mental health act assessment was conducted; David was referred to the Home Treatment Team and was seen by them on a number of occasions during which rapport was built and a plan for care going forward considered. David consulted with his GP again on 24th August and requested an urgent medication review. The GP advised that it would not be appropriate for her to make changes to his medication given that he was under the support of the Home Treatment Team, and, in evidence, said she thought the medication review would be undertaken by them. No medical review was conducted until 31st August, at which point alternative medication was prescribed, which was considered more appropriate to David’s symptoms. Later that evening, David was found dead at his home address of 52 King Arthur’s Road, Exeter, having suspended himself his family which was found He had written a note to . He . 9. CORONER’S CONCERNS During the course of the inquest I heard evidence 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. David first presented to the GP surgery on 16th May 2023, reporting a deterioration in his mental health. No follow up was initiated by the surgery despite David’s recorded past medical history of dissociated disorder, self-harm and suicide. There was no evidence that, on that occasion, there had been any consideration of referral to secondary or tertiary mental health services which may have been available to assist David and inform his care; 2. David presented to the GP surgery again on 26th June. He reported that he’d had a ‘severe mental breakdown due to ongoing psychosis’ which had resulted in him taking an overdose and being arrested for being in possession of a weapon, and he’d been advised by Police mental health services to contact his GP for support. When he spoke to the GP, David informed her that he considered his most significant issue currently was depression, and said that he had not taken Quetiapine since he moved to Exeter some years previously. Despite the fact that David indicated depression to be his overriding concern, he had taken an overdose which resulted in hospital attendance, and he’d not taken Quetiapine for some time (and seemingly for different symptoms), the GP prescribed Quetiapine, without seeking guidance or input from a psychiatrist or mental health professional about whether that was an appropriate medication in the circumstances. No routine follow up appears to have taken place following that consultation. The next communication does not occur until the GP is informed that there had been a further suicide attempt resulting in a Mental Health Act Assessment of David on 22nd August. 3. On 31st August 2023, when a medication review was conducted, it was established that David needed a different medication given his presenting symptoms. This medication amendment therefore did not take place until 15 weeks after David had initially sought help from the GP. 10. COPIES AND PUBLICATION OF THIS REPORT 3 I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: 1. The family of David Joyce 2. Devon Partnership NHS Trust I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. SIGNATURE 4
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.
GPs
Dr Carl
30th June 2026
Alison Longhorn
Area Coroner
Exeter & Greater Devon
County hall
Topsham Road
Exeter
EX2 4QD
Dear Graham
RE: David Paul Joyce
Address: 52 King Arthurs Road, Exeter, EX4 9BH
DOB: 12 Feb 1990 NHS Number: 472 813 7600 Date of Death: 31 Aug 2023
Mr Joyce spoke to myself
at Foxhayes Surgery on the 16 th May 2023 having separated
from his partner approximately a month earlier. This had affected David’s mood he reported that he
was struggling, lacking motivation and struggling to leave the house. He hadn’t been to work and had
taken the previous 7 nights off. He had been spending time with his friends but was struggling to pick
himself back up. David had a history of diagnosis with dissociative disorder dating back to 2018 but
no episodes of any mental health problems in the 5 years to his phone call on the 16 th May. I had a
long conversation with David that morning we talked about benefits and pitfalls of sick notes and the
best methods to get himself back on track. We talked about aiming to return to work, spending time
outdoors, visiting friends and doing some form of exercise. I discussed that a sick note may lead to
The Foxhayes Surgery
117 Exwick Road, Exeter, EX4 2BH
E: foxhayes.prescriptions@nhs.net
www.foxhayespractice.nhs.uk
GPs
Dr Carl
a further deterioration in David’s mental health and agreed not to sign him off. I asked David to get
back in touch with the practice should he not be able to turn things around.
We would not typically refer an individual onto secondary or tertiary services presenting initially who
is experiencing difficult life events. We speak to a very large number of patients who are struggling
with life events including separation from partners that typically need time to resolve. Patients need
to feel heard, understood and supported and I think we have a duty to offer appropriate pragmatic
advice to patients on managing difficult life events. We always safety net at the end of our
consultations and discuss appropriate follow up and additional support should the individuals not be
able to keep on top of their symptoms and problems.
David was seen on the 23rd of June in the Emergency Department of the Royal Devon & Exeter
Hospital following a possible paracetamol overdose. David was also reviewed on the same day 23rd
June whilst in Police custody by
a Senior Mental Health Practitioner working for the
Devon Liason and Diversion Service. He was reported by
to be suffering from low mood. She
gave him a support plan listing local sources of support. She did note report or refer him to the
community Mental Health team or secondary Care Services. David contacted the surgery by econsult
at 13:30 on the 26th June he was called back at 16:00 that day by
plan
after talking to David was to represcribe the Quetiapine which he found useful but had stopped taking
this since his move to Exeter. She also agreed she would contact the Mental Health Practitioner who
had reviewed David at the weekend to discuss a referral to the Mental Health Team. She provided
him with contact numbers for The Moorings who are able to provide urgent counselling, Access &
First Response Team and the Samaritans. Unfortunately, there is no follow up with regard to
The Foxhayes Surgery
117 Exwick Road, Exeter, EX4 2BH
E: foxhayes.prescriptions@nhs.net
www.foxhayespractice.nhs.uk
GPs
Dr Carl
attempts to contact the Mental Health Team. I am unable from the medical records to
ascertain whether she managed this or not.
David contacted the Access & First Response Service on the 6th August during that consultation he
reported that he had no thoughts of harm to himself or others. He was sent resources for self-care
that he would look through with his sister. He was given advice about healthier activities going forward
to help him get over his recent separation.
David was next assessed by the Mental Health Team following his detainment on a 136 Section on
the 22nd August. He was seen by
, Consultant Psychiatrist and
Independant Registered Medical Practitioner and
, Approved Mental Health Professional
on the 23rd August. The outcome of this meeting was that David was not detained he was discharged
back into the community, and he agreed to work with the Home Treatment Team, he was referred to
Together to support his current alcohol consumption and breathing space to look at his financial
issues. David’s case was opened by the Home Treatment Team on the 24th August. David contacted
Foxhayes Surgery at 17:45 on 24th August following his review by the Home Treatment Team. He
felt that he needed an urgent medical review as his Quetiapine was not helping.
was not
comfortable changing his dose of Quetiapine as he was under the specialist care for this and had
seen his consultant psychiatrist the day before and the Home Treatment Team earlier that day. He
had a pending follow up appointment on the 26th August with the Home Treatment Team. A
prescription for his current and ongoing dose of Quetiapine was sent to the pharmacy on the 25 th
August by
. I believe it would be unusual for a GP to carry out a medication change for a
complex mental health patient who was reviewed less than 24 hours earlier by a Consultant
Psychiatrist and the same day by the specialist Mental Health Home Treatment Team. Any changes
The Foxhayes Surgery
117 Exwick Road, Exeter, EX4 2BH
E: foxhayes.prescriptions@nhs.net
www.foxhayespractice.nhs.uk
GPs
Dr Carl
made would I’m sure would be questioned by coroners in the future were it felt these changes may
have been implicated in an episode of self-harm or suicide. Enquiring why the GP felt more
experienced or qualified to make changes not deemed appropriate by a consultant less than 24 hours
earlier.
Having closely reviewed the medical records for David I sat down with the medical team at the practice
to review his medical records and actions by the individual doctors and the practice . The consensus
was the practice should have been more proactive on the 26th June when David represented making
a formal referral to the Community Mental Health Team and possibly the CRISIS Team for urgent
support given how David’s mental health had deteriorated in the 5 weeks prior to review.
attempt to call and speak to
following her review of David whilst in Police
custody clearly caused a breakdown in the formal referral process for David at that time.
However, had
, (a Senior Mental Health Practitioner) felt that David needed support from
the Mental Health Team whom she works for I would have expected her to make that referral when
she saw him on the 24th June. The practice felt there needs to be improved lines of communication
between Primary Care and the Community Mental Health Team including consultants and Home
Treatment Team for a patient who is currently under their care. Usually, the Mental Health Team take
ownership and responsibility for prescribing and dose changes for anti-psychotic medication as they
had for David. It would be unusual for a General Practitioner to then step in and alter the dose or
medication whilst under the expert care of Consultant Psychiatrists (who they saw the day prior and
chose not to make any medication changes and was also reviewed that day by the Home Treatment
Team who also decided not to make any medication changes). It seemed there was disjointed
The Foxhayes Surgery
117 Exwick Road, Exeter, EX4 2BH
E: foxhayes.prescriptions@nhs.net
www.foxhayespractice.nhs.uk
GPs
Dr Carl
support from different arms of Devon Partnership Trust with no joined up or cohesive care for David
provided by Devon Partnership Trust.
The practice has reviewed and looked at how we support, refer on and liase with Mental Health Team
for high-risk patients presenting with psychotic symptoms. The practice recognises that the referral
approach on the 26th June was reliant upon return phone calls or emails from the Mental Health Team
and as these did not happen the referral intention was lost. It is important that these processes are
formalised, and protocols put in place to ensure follow up by clinicians and the admin administration
team at the practice to ensure this does not happen again.
The Practice Manager has enrolled on a Patient Safety Incidence Response Framework Course so
that we can review our practice against the updated patient safety incident response standards and
understand how to respond proportionally to patient safety incidents, explore and understand the
patient safety incident profiles. The practice is due to hold a significant event analysis in July of this
year to review David’s case and explore ways to ensure that the practice is maximally supporting
vulnerable patients such as David.
Yours Sincerely
The Foxhayes Surgery
117 Exwick Road, Exeter, EX4 2BH
E: foxhayes.prescriptions@nhs.net
www.foxhayespractice.nhs.uk
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