A MENTAL health watchdog has launched an investigation after a troubled man with a history of suicide attempts killed himself.
The Mental Health Act Commission is carrying out an urgent probe into the tragic death of Steven Durbridge, who took an overdose of prescription medication days after he was discharged from a mental hospital in Havant.
Mr Durbridge, 41, was only supposed to be allowed enough drugs to last a few days at a time but was mistakenly prescribed a month's supply.
Days later he was found dead in his bedsit with 20 times the prescribed dose of painkillers and five times the prescribed dose of anti-depressants in his blood.
At an inquest into his death, Derek McCarthy, an inspector for the Mental Health Act Commission, said he was told Mr Durbridge had only been getting short prescriptions. This was to limit the number of tablets he had access to after he was discharged from hospital in February last year.
But his GP Dr Ruzanne Roux from Bosmere Medical Practice, Havant, revealed the surgery was giving him prescriptions for up to 100 tablets at a time.
At Portsmouth Coroner's Court she said: 'Usually communication between services is good but we were not aware he should only have been on a limited dose.'
Care staff at Mr Durbridge's bedsit at The Oaks, a house for mentally disabled adults in Oak Park Drive, Havant, broke into his bedroom on February 20 last year after he was reported missing and found him slumped on his bed.
He had told neighbours he was going away and so could have been dead for up to five days.
Coroner David Horsley said: 'I think sooner or later Steve would have taken his own life but it is quite clear there was an opportunity to get more medication than he was supposed to have.
'The issue needs to be addressed to prevent a similar thing happening in the future.'
Mr Durbridge was allowed to control his own medication – despite a string of suicide attempts stretching back to 1995.
In the past he had set fire to himself, tried to hang himself twice and taken more than two overdoses.
Mr Horsley, who will now write to Hampshire Partnership NHS Trust, which is responsible for mental health services, added: 'I'm concerned about the self-medication regime for Steven, particularly in light of the fact that he hoarded tablets in the past.'
A review was carried out following Mr Durbridge's death last year which found no failings, but the trust said it will review the result in light of information revealed at the inquest.
But Mr McCarthy said he would be carrying out his own investigation.
'I will be approaching the partnership trust with a list of very specific questions.
'It does raise questions about the communication between the GP and the hospital and whether one hand knows what the other hand is doing.'
Jane Elderfield, director of operations for Adult Mental Health Services at the trust, said in a statement: 'We take the care and wellbeing of patients extremely seriously.
'The trust was satisfied all reasonable steps had been taken to avoid such an incident.
'We will review our own internal investigation now the inquest into Steven's death has taken place.'
The coroner recorded a verdict that Mr Durbridge took his own life, but did so while suffering from serious psychiatric illness.