On 24 August 2012 I commenced an investigation into the death of JULIA SHIREEN DELL then aged 45. The investigation concluded at the end of the inquest on Monday 13 January. The conclusion of the inquest was that was Mrs Dell took her own life. She died of multiple injuries having been witnessed to jump from cliffs at Duckpool Beach, Kilkhampton, Bude in Cornwall

I found that the cause of Mrs Dell’s death was multifactorial. I found that the initiating and most significant event was the collapse and then liquidation of the family business. Other contributory features included:

(A) An increasing realisation that her children were leaving home; (B) The fact that her parents had recently informed her they intended to move to St

Albans; (C) Pressures relating to her work; (D) A feeling of being controlled by family members; (E) Confusion and/or a lack of compliance in taking the medications prescribed to her (F) Difficulties in her marital relationship; (G) The probability that she was suffering from a form of bi-polar disorder.

In particular, I would ask you to consider whether it is appropriate to have a formal handover where patients pass from one doctor to another within the surgery. This would seem more relevant where there are urgent or ongoing medical problems.

I would also ask you to consider whether it is appropriate, on all occasions, simply to place reliance upon a discharge letter and care plan without additional enquiry. That seems to be particularly the case where a discharge takes place in circumstances that appear at odds with the knowledge known to the doctors within the surgery.