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The Inquest into the death of 19 year-old Josh was heard before a jury and HM Assistant Coroner, Mr David Manknell KC, at the Inner South London Coroner’s Court from 20 – 28 March 2024.

The jury found that the circumstances of Josh’s death were as follows:

The deceased was a man with a history of mental illness and suicide ideation. He made 2 suicide attempts in 2018 which resulted in mirtazapine prescription from the GP. Subsequently, he was referred to SLAM (Community Mental Health), whom he saw for the next 9 months.  During 2018/19 he was experiencing multiple stressors in his life.

On 18 September 2019, he was happy to be discharged from SLAM, and refused therapy as he wanted to get on with his life. He was formally discharged with a letter on 15 October 2019. He had an appointment with a GP on 29 October 2019. Following a panic attack, and was prescribed 84 Propranolol tablets for acute symptoms.

Subsequently, he received further prescriptions for Propranolol at 84 tablets (on 26 November 2019 and 4 January 2020). On 2 December 2019 he met with the GP and the GP suggested reducing the Propranolol medication.

On 18th January 2020, there was a family event, which [Josh] decided not to attend. In the early hours of 19th January 2020, he contacted a friend, to say that he intended to take his life, and that friend then contacted the police. Police and ambulance were dispatched.  The police attended at 02:45 on 19th January 2020. [Josh] denied sending the text and declined help.

The police left and cancelled the ambulance.

[Josh] was later found collapsed and unresponsive in the bathroom at 04:50. First responders (ambulance) arrived at 04:54 and started CPR. [Josh] was transported to hospital and arrived in cardiac arrest (asystole). [Josh] was pronounced dead at 08:26 on 19 January from Propranolol overdose.”

Significantly, the jury concluded that:

·         the police were not fully informed of the level of risk to Josh’s life as markers of ‘suicide’ or ‘self-harm’ should have appeared on the PNC; 


·         this resulted in inadequate questioning from the officers on their attendance at 02:45 which could have led to Josh’s family, who were asleep in the house at the time, being alerted at an earlier stage; and


·         the inappropriate action of cancelling the ambulance, who may have made the appropriate mental health assessment.  

Although they were not directly asked to determine this issue, the jury expressed concern with the evidence they heard in relation to SLAM’s mental health services which suggested that Josh was: 

·         lost in the system.

·         his medical records were not shared with the GP.

·         Josh did not have his autism (ASD) test.

The jury considered that these may have been factors that contributed to Josh’s death.

While the jury found that the prescription of Propranolol was appropriate by Josh’s GPs, the Assistant Coroner was sufficiently concerned about the risk of future deaths by Propranolol overdose that he issued a Prevention of Future Deaths report to NHS England about the risk of prescribing Propranolol. This comes after the Inquest heard about a report that was released just weeks after Josh’s death by the Health Services Safety Investigations Body about the Potential under-recognised risk of harm from the use of propranolol”. 

Emma Gilbert, Solicitor for the Family said:

“Every so often you get a refreshing case where the inquest system works as it ought to; where the Family get a full explanation on the circumstances in which their loved-one died and their concerns about what may have gone wrong are taken seriously. This was one of those cases. It was evident to everyone in that courtroom that Josh was so well-loved and supported by his Family, particularly his mother and step-father who were present for every day of the proceedings. The heart wrenching circumstances of Josh’s death leave you with the sinking feeling that if the officers had asked Josh to wake up his parents when they attended at 2:45am, the outcome may have been very different. The jury’s conclusion is a stark reminder that it is not only important to members of the public for there to be co-ordination between public services but for those services to use all of the information and resources available to them to make decisions, especially family.”  

Josh’s family was represented by Emma Gilbert of Imran Khan and Partners Solicitors and Saoirse Townshend of Temple Garden Chambers.


Please contact Ms Emma Gilbert at 020 7404 3004 or for further details.


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