A coroner has warned that there is a risk of future deaths without “national guidance or timelines in place for the administration of medication” to someone experiencing mental health agitation or crisis.
According to a prevention of future deaths report published on August 14, Jake Read was 29 when he took his own life after visiting Ipswich Hospital’s emergency department seeking support for his mental health.
The report said that Read arrived at the hospital at 4:36pm on May 3, 2025 “in an agitated state” and was seen by two members of the mental health liaison team at 5:30pm.
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At around 6:30pm, the liaison team decided that Read needed a dose of Diazepam to “calm his agitation” prior to a mental health assessment.
Clinical observations to ensure there was “no contraindication to the dose being given” were completed at 6:35pm - but senior coroner for Suffolk Nigel Parsley said Read was not prescribed diazepam until 21:19pm, “some two hours and 44 minutes after” the observations took place.
Read was believed to have left the hospital sometime between 7:00pm and 7:30pm, and was found deceased in his home two days later, having taken his own life “on or before” May 5, 2025.
The coroner concluded that Read “must have intended his own death, on a background of failing mental health”.
Coroner’s concerns
Parsley identified several issues which may have contributed to Read’s death, however his “primary concern” was the lack of “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”.
He highlighted 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”, yet “no such guidance exists for the administration of drugs in mental health cases”.
“Tragic sequence of events”
While Parsley acknowledged that it was “not possible” to say whether the administration of diazepam would have prevented Read’s death, he maintained that there was a chance that “it might have changed the tragic sequence of events”.
According to the report, clinical staff said that a timeline “would have prompted staff to prescribe and administer the necessary drug earlier than it was”.
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Parsley also raised concerns over clinicians’ lack of “direct access” to diazepam.
He said that one of the mental health liaison team members who spoke to Read was a qualified non-medical prescriber, yet was unable to access the necessary drug, instead having to “request an emergency department clinician to prescribe it for them”.
It was this lack of access that led to the two-hour, 44-minute delay between observation and prescription of the diazepam.
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Parsley noted that changes have since been implemented at Ipswich Hospital allowing non-medical prescribers from the mental health liaison team to access and prescribe medications independently when in the emergency department, but he said it could not be ascertained whether the same provision was in place for all hospitals.
The report was sent to Ipswich and Colchester Hospital, as well as Norfolk and Suffolk Foundation Trust.
It said that unless action is taken to address the coroner’s concerns, there “is a significant risk of future deaths”.
