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This case concerned the death of a young man suffering from schizophrenia who tragically committed suicide in extremely violent circumstances by inflicting numerous wounds upon himself shortly after a change in his prescribed medication. The inquest raised issues about the proper scope of an investigation into a death in such circumstances, and the potential engagement of Article 2 ECHR. Evidence was heard from the representatives of the NHS Trust responsible for his treatment, the ambulance service and police, and a number of medical experts in the field of psychiatry and pharmacology, including those specially instructed by the family of the deceased. The Coroner noted issues concerning the method of change in the deceased’s medication, and the time taken for the police and ambulance services to attend to the deceased after being notified that he was harming himself on the day of his death.

Hanif Mussa acted for the family of the deceased, in conjunction with the mental health charity Rethink.

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