Finding into death of GAMcM
Deceased
GAMcM
Demographics
45y, male
Date of death
2017-07-31
Finding date
2021-07-30
Cause of death
Hanging
AI-generated summary
A 45-year-old man with depression died by hanging after experiencing significant workplace stress. He had consulted his GP in October 2014 regarding grief over his mother's terminal illness and was prescribed sleeping tablets. He was diagnosed with depression in March 2015, started on sertraline, and improved. After stopping sertraline around June 2016, he separated from his wife in November 2015. In May 2017, he presented with low mood, refusing antidepressants initially. Following a performance management process at work in July 2017—triggered by concerns about his motivation and performance—he became distressed and restarted sertraline on 21 July. On 19 July, he learned he faced performance management, no bonus, and possible dismissal. He died by hanging on 31 July 2017. Clinical lessons include: recognising depression recurrence risk in vulnerable patients who cease antidepressants; identifying workplace stress as a significant suicide risk factor; and ensuring employer awareness of employees' mental health conditions during performance management processes.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Depression with prior history and treatment interruption
- Workplace performance management process
- Threat of job loss and loss of bonus
- Recent marital separation
- Low motivation at work
- Workplace conflict with management
- Workplace stress
- Lack of confidence and low self-esteem
Coroner's recommendations
- The Company should assiduously evaluate their internal processes and procedures for dealing with employees considered not to be performing up to expectation and explicitly consider strategies for minimising the inevitable stress caused by such processes and procedures, particularly in employees with mental ill-health
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