On 17 January 2024 I commenced an investigation into the death of Nicholas Paul MURPHY aged 48. The investigation concluded at the end of the inquest on 28 July 2025. The conclusion of the inquest was that: On the 9th January 2024 Nicholas Paul Murphy was found deceased at his home address in Hurstbourne Place, Southampton. He was last seen on the 29th December 2023 when the ambulance service attended his address and he reported that he had taken an overdose. He declined to go to hospital and refused further assessment after which the ambulance staff left.

Nicholas had struggled with mental health and addiction difficulties for a long time. He reported worsening mental health in 2023 which was impacted by antisocial behaviour around the area of his property and financial difficulties. On the 29th December 2023 he sent an email at 3.09am saying that he had taken an overdose and, at some point, posted a message on Facebook saying that he was attempting to overdose. The post was seen by his family who called 999 and reported this to the police. They were directed to request an ambulance which they did. An ambulance attended Nicholas and the crew were allowed into the property just after 6.30am. He reported to the ambulance crew that he had taken an overdose of at 0.30am. The crew completed physical observations which revealed normal cardiovascular and respiratory functions. He did not display any overt signs of having taken an overdose. Nicholas then withdrew his consent for further assessment and required the ambulance crew to leave. Nicholas was assessed as having mental capacity to make this decision and the crew left the property. The electronic Patient Clinical Report completed by the crew gave an accurate account of these events. However on the call log completed by the ambulance crew the outcome was given as ‘Advice only’. The police contacted the ambulance service later on the 29th December to ask for an update and were advised that the patient had been seen and left at home. The police asked if there were any further concerns and were told that there was nothing to indicate that the attending crew had any concerns. I heard evidence that the police may have visited Nicholas had they been informed of the full circumstances of the crew’s attendance. I also heard evidence that the outcome or disposition codes available for the ambulance crew on the call log are nationally mandated. It is these logs that are readily available to staff in the ambulance service contact centre. The available outcome codes do not include one that states ‘Patient refused treatment/declined transfer to hospital’ or anything similar. In order to access the fuller information the ambulance call centre operator would have to enter more detailed records than those available on the face of the call log. They are under pressure at work and therefore there is a risk that this might not be done as was likely to be the case here. Nicholas was found deceased in his flat on the 9th January 2024 after a further concern for his welfare was raised with the police. He had taken an overdose of It was not possible to establish exactly when Nicholas took the overdose.