On 25.10.2016 commenced an investigation into the death of Lester John STACEY. The investigation concluded at the end of the inquest on 9.3.2017. The conclusion of the inquest was Suicide the cause of death was hanging_ CIRCUMSTANCES OF THE DEATH The deceased had a history of hypertrophic cardiomyopathy and mental health issues_ He had been diagnosed with bi-polar affective disorder_ He had contact with mental health services from 2005 to 2014 and was re-referred in May 2016. He received some in-patient care but on discharge he failed to engage with community services and was subsequently discharged His medication was changed at this time. He had recently had some worries regarding his business and had been suffering with low moods_ At about 1800 hours on the 23rd October 2016 he was found hanging in a barn at his home address, The Oaks, Green Lane, Eccleshall: He was certified dead at the scene There was no third party involvement. CQRONERS CQNCERNS During the course of the inquest the evidence revealed matters giving rise to concern: In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you: The MATTERS OF CONCERN are as follows The deceased was admitted as an In-patient under S2 Mental Health Act from 16 May 2016 to 19 May 2016. He was discharged without being given follow up appointments He subsequently failed to respond to telephone calls and letters to attend appointments. He was therefore discharged from the service on the 21 June 2016. Joy

There was no attempt t0 visit him during this period to try and re-engage him with services_ He may not have received the correspondence inviting him for appointments because he was away on holiday for some of that period. He might have benefitted from having pre-arranged appointments prior to his discharge. His medication was changed during his last admission and thereafter does not appear to have been monitored_ The deceased was said to have lacked confidence in the new medication and may not have been totally compliant Family perception was that he responded less well to the changed medication. ACTION SHOULD BE TAKEN In opinion action should be taken to prevent future deaths and believe you have thepower to take such action; YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report; namely by 5"6 20171, the coroner; may extend the period: Your response must contain details of action taken or proposed to be taken, setting out the_timetable for action Otherwise YOu must explain why no action is proposed COPIES and PUBLICATION sent a copy of my report to the Chief Coroner and to the following Interested Person, am also under a duty to send the Chief Coroner a copy of your response_ The Chief Coroner may publish either or both in a complete or redacted or summary form_ He may send a copy of this report to any person who he believes may find it useful or of interest You may make representations to me, the coroner; at the time of your response, about the release or the publication of your response by the Chief Coroner. 10h March 2017 Margaret J Jones Assistant Coroner Staffordshire (South) Coroner's Office No 1 Staffordshire Place Stafford ST16 2LP Tel No: 01785 276127 Fax No: 01785 276128 sscor@staffordshire.gov uk my May have

The deceased had a history of hypertrophic cardiomyopathy and mental health issues_ He had been diagnosed with bi-polar affective disorder_ He had contact with mental health services from 2005 to 2014 and was re-referred in May 2016. He received some in-patient care but on discharge he failed to engage with community services and was subsequently discharged His medication was changed at this time. He had recently had some worries regarding his business and had been suffering with low moods_ At about 1800 hours on the 23rd October 2016 he was found hanging in a barn at his home address, The Oaks, Green Lane, Eccleshall: He was certified dead at the scene There was no third party involvement.

In opinion action should be taken to prevent future deaths and believe you have thepower to take such action;