A CORONER has raised their concerns over the death of a man after a local GP practice failed to record reviews of his mental health or his medication and they say there is risk that future deaths will occur unless action is taken.
David Stables had a history of mental health issues and had taken two drug overdoses in 2020.
He was subsequently prescribed sertraline a type of anti-depressant in April 2020 and weaned himself off it in 2023.
David’s last prescription was issued to him in July 2023.
However a report, which has been sent to the Chief Coroner, shows that there were no records of any mental health support given to David by his GP Dearne Valley Practice, based in Thurnscoe.
The report states: “David attended many appointments at his GP practice from 2020 to 2023 regarding other issues unrelated to his mental health.
“In most of these encounters there is no record of any discussions regarding his mental health.
“Whilst he received repeat prescriptions for his sertraline, there are few records of a review of his mental health or appropriateness of the medication.
“I am concerned that there were no recorded mental health or medication reviews from April 2020 until February 2024 when David attended the GP asking for help.
“In February 2024 he attended the GP surgery and had a face to face appointment regarding his mental health.
“He had anxiety and had difficulties in sleeping and poor appetite.”
A decision was then made to put David on mirtazapine another antidepressant at 15mg and to follow up in four weeks time.
The report added: “On March 18, 2024 he was seen again by the GP and there was some improvement.
“I was told that self harm and suicidal ideation were specifically discussed and they were strongly denied at both appointments.
“There was no concern from the GP when he called two days later to ask to increase his medication although it was accepted that had she known he had tried to contact the GP surgery then this may have
changed her management in terms of obtaining more information either by reception or by another appointment.
“However, I do find that whilst he may have attempted to contact the GP it cannot be ascertained if these calls actually made it through to the reception team.”
Marilyn Whittle, assistant coroner for the ‘South Yorkshire West’ region, began an investigation into David’s death on March 28.
The investigation ended at the end of the inquest which concluded earlier this month.
She said: “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.
“I am concerned that there were no recorded mental health or medication reviews from April 2020 until February 2024 when David attended the GP asking for help.
“I was unable to establish whether these reviews had taken place and just not been recorded or whether full mental health reviews had not taken place when they should have been.
“In my opinion action should be taken to prevent future deaths and I believe Dearne Valley Practice have the power to take such action.”
Dearne Valley Practice now has until January 31 to respond to the report.
A spokesperson said: “We are very sorry about Mr Stables’ death and express our sincere sympathies to his friends and family.
“We have noted the report from the coroner and will be responding within the allotted time frame.
“We cannot comment further due to our duty of patient confidentiality.”
