Christopher Stubbs
PFD Report
Historic (No Identified Response)
Ref: 2016-0081
No published response · Over 2 years old
Response Status
Responses
0 of 1
56-Day Deadline
28 Apr 2016
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’S Concerns
During the course of the inquest I heard that Christopher’s prescribed medication of mirtazapine and pregabalin was stopped by the acute
hospital doctors on his discharge from the hospital following his overdose of 7 February 2015, pending a further review by his GP, which I heard did not take place prior to his death.
The MATTER OF CONCERN is as follows. –
To review the effectiveness of existing office systems and procedures in relation to the receipt of discharge summaries from hospitals which advise on the review of patient’s medication.
hospital doctors on his discharge from the hospital following his overdose of 7 February 2015, pending a further review by his GP, which I heard did not take place prior to his death.
The MATTER OF CONCERN is as follows. –
To review the effectiveness of existing office systems and procedures in relation to the receipt of discharge summaries from hospitals which advise on the review of patient’s medication.
Report Sections
Investigation and Inquest
On 30 July 2015 I opened an inquest into the death of Christopher John Stubbs who, at the date of his death, was aged 36 years old. The inquest was resumed and concluded on 20 February 2016 I found that the cause of death to be: ‐
1a. Hanging
I arrived at a conclusion of suicide.
1a. Hanging
I arrived at a conclusion of suicide.
Circumstances of the Death
On 26 July 2015 Christopher John Stubbs, who had a history of mental ill health and drug misuse and a previous attempt to take his own life by drug overdose on 7 February 2015, was found suspended from a ligature made from a bath robe cord attached to a door on the landing of his home address. It was found that he intended to take his own life.
Copies Sent To
I have sent a copy of this report to
Bradford District Care NHS Foundation Trust
NHS England
Chief Coroner
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.