“My primary concern in Jake's case is that evidence heard that there is no national…”

The coroner’s concerns

My primary concern in Jake's case is that evidence heard that there is no national guidance or timelines in place for the administration of medication required in cases where an individual has been identified as being in a state of Mental Health agitation or Mental Health crisis. On the 3rd May 2025 Jake arrived at the Emergency Department of the Ipswich Hospital at 16:36. Jake was identified as requiring a consultation with the Mental Health Liaison Team at 17:05. Two staff from the Mental Health Liaison Team first met Jake at 17:30. At approximately 18:20-1830 it was identified that Jake required a dose of Diazepam to calm his agitation, to allow for a more effective Mental Health Assessment. Prior to administration of the Diazepam clinical observations were required and these were being completed at 18:35. The observations showed no contraindications for the administration of Diazepam. However, the Diazepam was not prescribed to Jake until 21:19, some 2 hours and 44 minutes after the clinical observations had shown no contraindications for the administration of Diazepam. It is believed that Jake had left the Emergency Department at some time between 19:00 and 19:30. It was not possible to identify on the available evidence whether the administration of Diazepam to Jake on the 3rd May would have prevented his death. However, it was acknowledged that there was a chance that had the Diazepam been administered, it might have changed the tragic sequence of events leading to Jake's death. Evidence heard that in some medical cases clinical staff are given a clear timeline in guidance as to when it is expected a required medication is to be administered (sepsis being cited as an example). The court was told that no such guidance exists for the administration of drugs in Mental Health cases. In Jake's case clinical staff stated that had such a timeline been in place, this would have prompted staff to prescribe and administer the necessary drug earlier than it was. My second concern is that at the time of Jake's attendance on 3rd May 2025, one of the Mental Health Liaison Team staff who spoke to Jake at 17:30 was a qualified Non-Medical Prescriber, who could have prescribed the Diazepam to Jake herself. However, at that time, even though a Mental Health Liaison Team NonMedical Prescriber had assessed Jake required an immediate dose of Diazepam, this clinician had no direct access to the required drug. Therefore, at that time, the Non-Medical Prescriber had to request an Emergency Department clinician to prescribe it for them. In Jake's case this caused the 2 hours and 44-minute delay between clinical observations being completed and drug prescription being made. Evidence was heard that the East Suffolk and North Essex NHS Trust and the Norfolk and Suffolk Foundation Trust have changed the system at the Ipswich Hospital, and now the Mental Health Liaison Team Non-Medical Prescribers are able to both prescribe and access prescription medications within the Emergency Department, without the need to request an Emergency Department clinician to prescribe it for them. When asked, the witness providing this evidence could not say whether the same provision was available in hospitals other than those covered by the relevant trusts. As such, it is not known if direct access to Mental Health medication by Mental Health clinicians working in an Emergency Department is just a local arrangement, or if it is replicated in other jurisdictions? 11. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: [please do not use individual’s names, but instead roles/titles]    Ipswich and Colchester Hospital (Legal Services) NSFT - Norfolk and Suffolk Foundation Trust (Legal Services) I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. 12. SIGNATURE Nigel PARSLEY HM Senior Coroner for Suffolk

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0308

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0