David Joyce

“[the deceased] 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 [the deceased]'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 [the deceased] and inform his care”

“[the deceased] 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, [the deceased] 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 [the deceased] 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”

“On 31st August 2023, when a medication review was conducted, it was established that [the deceased] needed a different medication given his presenting symptoms. This medication amendment therefore did not take place until 15 weeks after [the deceased] had initially sought help from the GP”