Inquest into the death of James BARTON

21y · Male·external neck compression due to hanging; intentional self-harm

James Barton, aged 21, died by suicide on 27 March 2013, three days after discharge from psychiatric care. He was appropriately assessed and admitted as a mentally disordered person on 3 March following a deliberate overdose of 30 ecstasy and 5 Xanax tablets. Dr N. discharged him on 4 March. On 23 March, following another acute presentation with suspected overdose, Dr S. assessed him as low risk and discharged him. Expert evidence established that while interpretation of Mental Health Act criteria was reasonably within acceptable practice, critical gaps existed: (1) non-prescribed Xanax tablets were incorrectly returned to him on discharge on 4 March due to misplacement in hospital drug storage with an inappropriate label; (2) no consultation occurred with the discharging clinician before returning medication to an overdose patient; (3) risk assessments did not adequately synthesize concerning clinical factors. The coroner made no adverse findings against clinicians but recommended policy changes regarding medication return procedures for patients admitted with deliberate self-poisoning.