David Joyce
Response Status
Report Content
Coroner
I am Alison LONGHORN, Area Coroner, for the County of Devon, Plymouth & Torbay.
Legal Powers
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DATE OF REPORT 25th June 2026
Legal Powers
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
Your Response
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. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online . The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary.
Action Required
In my opinion, unless action is taken to address the concerns below, then there is a significant risk of future deaths, and I believe you have the power to take such action.
Investigation and Inquest
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A coronial investigation was commenced on 1 st September 2023 into the death of David Paul Joyce, aged 33, who had been found deceased on 31 st August 2023 at his home address of 52 King Arthur’s Road, Exeter, having ligatured [REDACTED]. 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.
Circumstances of Death
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David Joyce had a history of mental health difficulties. In 2018 a psychiatric review diagnosed that David was having an acute dissociative episode and he was prescribed Quetiapine. In the summer of 2023, having had a period of some stability, his mental health deteriorated following the breakdown of a relationship, and he was experiencing feelings of low mood and having difficulty sleeping. He initially consulted the GP about this on 16th May and was encouraged to go back to work and get out of the house. 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].
Details
- Report Date
- 25 June 2026
- Coroner
- Alison Longhorn
- Coroner Area
- Devon, Plymouth and Torbay
- Reference
- 2026-0295
If you need support right now:
Samaritans — 116 123, free, 24 hours
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Cruse Bereavement — 0808 808 1677, weekdays 9am–5pm