Joseph Powell
PFD Report
All Responded
Ref: 2025-0234
All 1 response received
· Deadline: 12 Jul 2025
Response Status
Responses
1 of 1
56-Day Deadline
12 Jul 2025
All responses received
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
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. 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.
Responses
The RCGP will highlight this case to its Mental Health Special Interest Group to promote safety planning in suicide prevention and consider GP booking of follow-up appointments as part of a safety plan for patients with mental health conditions.
AI summary
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Dear Ms Murphy
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.
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.
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.
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.
Report Sections
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.
The medical cause of death was: 1A Hanging 2 Post traumatic stress disorder and depression.
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.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.