Coroner's Finding: Sowden, James Robert

65y · Male·Self-inflicted incised and stab wounds to neck and incised wounds to wrists

James Robert Sowden, aged 65, died by self-inflicted neck and wrist wounds on 28-29 March 2018. He had a history of depression with paranoid features (diagnosed 2003) and autoimmune thyroiditis. In the week before death, he experienced adverse medication effects (paranoia, panic attacks) after being prescribed antidepressants for worsening depression and anxiety. He presented to ED after self-harm (striking himself with hammer) and was assessed by CATT. Critically, the registered nurse did not conduct a face-to-face psychiatric assessment—the consultant psychiatrist made discharge decisions based only on phone discussion without reviewing the patient. He denied suicidal ideation but was discharged home without documented risk management discussion with family. Key failures: inadequate collateral history-gathering, no formal capacity assessment, lack of face-to-face psychiatric evaluation despite acute presentation with lethal self-harm method, and absent family risk discussion at discharge. The RCA identified system improvements around risk assessment, handover protocols, and documentation.