David Joyce: Prevention of future deaths report

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The investigation concluded at the end of the inquest on 17^th June 2026. The medical cause of  death was recorded as 1a) asphyxia due to hanging and the conclusion was suicide. 

In June 2023, David was arrested having taken an overdose of paracetamol and caused  damage to his room; he was seen by the Criminal Justice Liaison & Diversion Team in custody and was referred for support and advised to contact his GP. He approached his GP and  disclosed that he had not been taking his Quetiapine since he’d moved to Exeter some years  previously, and that he considered his most pressing symptom now was depression rather 
than anger. The GP issued a prescription for Quetiapine, seemingly with no consideration of a  referral to mental health services, or any request for specialist psychiatric input regarding  appropriate medication.  

On 22^nd August, David was found in a local wood [REDACTED]. He 
was encouraged down and detained under the Mental Health Act. A mental health act  assessment was conducted; David was referred to the Home Treatment Team and was seen  by them on a number of occasions during which rapport was built and a plan for care going  forward considered. David consulted with his GP again on 24^th August and requested an  urgent medication review. The GP advised that it would not be appropriate for her to make  changes to his medication given that he was under the support of the Home Treatment Team,  and, in evidence, said she thought the medication review would be undertaken by them. 

No medical review was conducted until 31^st August, at which point alternative medication was  prescribed, which was considered more appropriate to David’s symptoms. Later that evening,  David was found dead at his home address of 52 King Arthur’s Road, Exeter, having suspended himself [REDACTED]  He had written a note to 
his family which was found [REDACTED]. 

The MATTERS OF CONCERN are as follows:
1.   David first presented to the GP surgery on 16^th May 2023, reporting a deterioration in his mental health. No follow up was initiated by the surgery despite David’s recorded  past medical history of dissociated disorder, self-harm and suicide. There was no  evidence that, on that occasion, there had been any consideration of referral to  secondary or tertiary mental health services which may have been available to assist  David and inform his care; 

2.   David presented to the GP surgery again on 26^th June. He reported that he’d had a  ‘severe mental breakdown due to ongoing psychosis’ which had resulted in him taking an overdose and being arrested for being in possession of a weapon, and he’d been  advised by Police mental health services to contact his GP for support. When he  spoke to the GP, David informed her that he considered his most significant issue  currently was depression, and said that he had not taken Quetiapine since he moved  to Exeter some years previously. Despite the fact that David indicated depression to  be his overriding concern, he had taken an overdose which resulted in hospital  attendance, and he’d not taken Quetiapine for some time (and seemingly for different  symptoms), the GP prescribed Quetiapine, without seeking guidance or input from a  psychiatrist or mental health professional about whether that was an appropriate  medication in the circumstances. No routine follow up appears to have taken place  following that consultation. The next communication does not occur until the GP is  informed that there had been a further suicide attempt resulting in a Mental Health Act Assessment of David on 22^nd August.  

3.   On 31^st August 2023, when a medication review was conducted, it was established that David needed a different medication given his presenting symptoms. This  medication amendment therefore did not take place until 15 weeks after David had  initially sought help from the GP.  

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You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be  sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional  information relating to the publication of reports and responses.