Joseph Powell

I am Sarah Murphy, Assistant Coroner for the coroner area of Cheshire.

On 09 September 2024 I commenced an investigation into the death of Joseph David  POWELL aged 28. The investigation concluded at the end of the inquest on 13 May 2025. The conclusion of the inquest was: Suicide against a background of post-traumatic stress disorder and depression. The medical cause of death was: 1A Hanging 2 Post traumatic stress disorder and depression.

The deceased was 28 years of age with a medical history of mental illness. In March 2024 he  was diagnosed with depression and was prescribed Sertraline for 28 days. He did not receive a further prescription for this as he had not booked a follow up appointment with his GP as  requested. On the 22 August 2024, he re-presented to his GP surgery and was diagnosed with post traumatic stress disorder and an exacerbation of his depression. He denied any  active suicidal thoughts but had experienced suicidal ideation. He was prescribed Citalopram,  and provided with a telephone number for a local psychotherapy service and agreed to make a follow up appointment for a review with the GP in one to two weeks’ time. He did not  subsequently book a review appointment with his GP. On the 6 th September 2024, he was found at his home address suspended [REDACTED]. He was cut down and cardiopulmonary resuscitation was commenced whilst waiting for paramedics to arrive. He did not respond to resuscitation and death was certified on the scene by paramedics at 21:24 hours.

During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the  circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: That not all GPs book follow up appointments for patients presenting with mental health difficulties such as depression, anxiety and post-traumatic stress disorder. Instead, they request that the patient book their own follow up appointment with  their GP. This can be difficult for patients who are suffering with mental health  difficulties and can result in patients not receiving a follow up appointment with their GP or any further medication.

In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.