Coroner in action call after suicide

Norfolk's coroner yesterday called for a review of mental health procedures after an inquest found that a man who committed suicide was failed by a string of professionals following his arrest.

Norfolk's coroner yesterday called for a review of mental health procedures after an inquest found that a man who committed suicide was failed by professionals following his arrest.

Lee Marsh, 42, died of an overdose of morphine and carbamazepine at his home at Bawburgh Road, Easton, near Norwich, in May 2005.

Five days earlier he had been arrested and held overnight at Bethel Street police station after assaulting his wife, Anita, and threatening a policeman with a shovel.

During his time in custody, forensic medical examiner Dr Harilal Kalaria authorised officers to continue giving him prescribed medication despite the fact that he had chosen not to examine him.

Following the nine-day inquest which heard from 22 witnesses, a jury yesterday recorded a verdict of suicide. However, its narrative verdict added that this was: "Contributed to in part by the fact that there had been no appropriate assessment of his mental health, including an assessment of the risk of suicide (based upon all the relevant information available) between his arrest on May 16, 2005, and his death on May 21, 2005, at a time when unusually he was living alone unsupported and unsupervised when he took an overdose of prescribed medication with the intention of ending his life and died as a result."

Coroner William Armstrong said that in light of this verdict he intended to write to Norfolk and Waveney NHS Mental Health Trust to consider whether measures could be taken to ensure all GPs are familiar with the role of the support on offer from various agencies.

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Mr Armstrong added: "I will contact the Council of the Registration of Forensic Physicians to see if there is a need for more proactive guidance to forensic physicians as to the circumstances, if any, appropriate to the authorisation of administration of medication to people held in police custody without seeing the patient."

Mrs Marsh refused to comment after the inquest but her brother, John Rourke, said: "I'm glad this inquest has highlighted the failing of the police, police doctor and the mental health trust."

A Norfolk police spokesman said the force welcomed the opportunity of participating in the inquest. He added: "The actions of our officers, those of a doctor at Mr Marsh's GP surgery, a forensic medical examiner and the local mental health trust have properly been the subject of intense and rigorous scrutiny.

"The death of Mr Marsh has been a tragedy for his family and friends. We extend our sympathies to them and hope that this inquest has served to fully explain the circumstances in which he died."

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