The MATTERS OF CONCERN following the inquest into Mr Viles’ death were as follows:

1. I heard evidence from several medical professionals regarding the risks that Mr Viles posed to himself and that this risk was recognised prior to his death.

You provided a statement, dated 5/1/25, for the inquest which set out the interventions that you and your colleagues had undertaken to treat Mr Viles’ back pain in 2023 and 2024. No reference was made to any prescriptions that you issued and therefore, given the medical cause of death that had been proposed, I did not summons you to attend the inquest. You did note that you had referred Mr Viles to a psychologist, who consulted with him on 19/6/24 and raised concerns regarding the need for urgent psychiatric input, given his suicidal ideation. You also noted that you reviewed him after the psychologist’s input and concluded that he was not suitable for spinal cord stimulation.

At the inquest it could not be determined from where Mr Viles had obtained the medication on which he overdosed. I therefore wrote a letter of concern to you, asking if you had prescribed medication (as had been suggested by the mental health trust’s evidence).

You replied on 13/6/25, setting out that you had prescribed four weeks’ worth of on 28/6/24 (nine days after the psychologist’s consultation).

I am concerned that you prescribed this medication after the psychologist you had referred Mr Viles to had raised significant concerns regarding his mental health.