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The lack of national guidance around the administration of medicines to patients experiencing a mental health crisis has been cited as a matter of concern following the inquest into the death by suicide of a 29-year-old man in May last year.

Jake Read was found dead from self-inflicted knife wounds at his home on the afternoon of May 5, 2025, two days after he attended Ipswich Hospital’s emergency department at 16:36 in what Sussex senior coroner described in a report to prevent future deaths as “an agitated state”.

Clinicians planned to give Mr Read a dose of diazepam ahead of a more thorough mental health assessment, pending clinical observations being carried out to ensure there were no contraindications.

However, the diazepam was not prescribed until 21:19, almost three hours after the clinical observations showed there were no contraindications for the administration of diazepam. Mr Read is thought to have left the emergency department at a time between 19:00 and 19:30.

The coroner acknowledged that it was not possible to say conclusively whether a diazepam supply on May 3 would have prevented Mr Read’s death but added: “However, it was acknowledged that there was a chance that had the Diazepam been administered, it might have changed the tragic sequence of events leading to Jake’s death.”

The coroner heard evidence that for some medical cases such as sepsis, clinical staff are issued with a “clear timeline” detailing when medicines should be administered.

However, “no such guidance” exists for mental health crises.

“In Jake’s case clinical staff stated that had such a timeline been in place, this would have prompted staff to prescribe and administer the necessary drug earlier than it was,” said the coroner.

The report also noted the evidence of a mental health liaison team member who spoke to Mr Read at 17:30 was a non-medical prescriber and could have prescribed diazepam but had “no direct access” to the drug and had to request an emergency department clinician to prescribe it.

This directly caused the delay of two hours and 44 minutes between the clinical observation being completed and the prescription being issued.

“Evidence was heard that the East Suffolk and North Essex NHS Trust and the Norfolk and Suffolk Foundation Trust have changed the system at the Ipswich Hospital, and now the mental health liaison team non-medical prescribers are able to both prescribe and access prescription medications within the emergency department, without the need to request an emergency department clinician to prescribe it for them,” the report said.

But the inquest did not establish whether this guidance is being implemented nationally.

The report was issued to the Department of Health and Social Care, which advised the coroner on August 10 that NHS England is the appropriate body to deal with these concerns.

Related: Diazepam prescribing guidelines not followed, finds coroner after suicide inquest

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