Trust criticised over man's care before his death

A Sheffield NHS trust has been questioned by a coroner about the "abrupt" withdrawal of antipsychotic drugs to a man who died by suicide.

South Yorkshire East coroner Nicola Mundy published a Prevention of Future Deaths report about Jason Ricardo White, following an inquest she held into his death in December 2024. The inquest concluded the cause of death was suicide.

Ms Mundy said there was "inadequate follow-up" after doctors stopped Mr White's medication, Olanzapine.

The Sheffield Health Partnership University NHS Foundation Trust has until February 13 to respond. Ms Mundy also said individual whose details were redacted from the report needed to respond by the same date.

The report said Mr White developed mental health symptoms in April 2024 "which were essentially depression and psychotic episodes".

"Mr White engaged with both his GP and mental health support services including the Priory hospital in Nottingham, Sheffield Teaching Hospitals NHS Trust, Sheffield Health Partnership University NHS Foundation Trust and Sheffield City Council to manage his symptoms," it added.

"He remained fixated on his symptoms being linked to serious medical complaints and appeared at no time to accept that the physical symptomology of which he complained was inextricably linked to his mental health challenges.

"Mr White received various levels of management which included medication. One of those medications was Olanzapine. This was ceased abruptly due to a belief that this was responsible for deranged liver function tests but there was inadequate follow-up thereafter."

Ms Mundy outlined three causes for concern.

These included a management plan of daily monitoring for Mr White not being followed, the Local Democracy Reporting Service reported.

This created "a risk of relapse in terms of psychotic symptoms and associated deterioration in mental health," according to Ms Mundy's report.

The report said there were risks of relapse when any medication was abruptly ceased.

It added that this "must be fully monitored; the absence of full assessment and monitoring exposes patients to risk of a serious deterioration in mental health".

Ms Mundy concluded: "During the course of the investigation my inquiries revealed matters giving rise to concern.

"In my opinion there is a risk that future deaths could occur unless action is taken."

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