Inquest into the death of Kenneth MAWBY

59y · Male·Suicide by hanging while suffering from a mood disorder in the nature of delirium causing behavioural changes including impulsivity following DBS surgery, with the mood disorder more likely than not due in significant but unquantifiable measure to the DBS stimulation in combination with medication

A 59-year-old man died by suicide on 5 January 2009, 47 days after undergoing Deep Brain Stimulation (DBS) surgery for Parkinson's disease. Post-operatively, he experienced significant behavioural changes including agitation, impulsivity, and mood disturbances. Critical failures in post-operative care contributed to his death: the treating neurologist (Professor Silburn) failed to arrange timely follow-up appointments despite documenting this plan at discharge, did not ensure the family understood the risks of behavioural changes, and provided no backup care during his leave over the Christmas period. The patient's family repeatedly tried contacting the neurologist unsuccessfully, ultimately seeing a different specialist. The coroner found DBS, in combination with medication, likely contributed to the mood disorder that increased impulsivity and suicide risk. Better informed consent, earlier post-operative review, continuity of care, and explicit emergency contact protocols could have prevented this death. System failures included poor communication, lack of written follow-up plans, and absence of contingency arrangements.