Coroner Rachel Spearing concluded there was a failure to fully support a family following the discharge of a psychiatric inpatient from St James' Hospital in Portsmouth, finding the decision to discharge was clinically appropriate but executed unsafely due to an inadequate risk assessment. Chris and Ruth Stone‑Houghton died at their home in September 2022; the coroner said the deaths could not have been predicted.
Mr Stone‑Houghton, 66, developed psychotic depression after his jewellery business closed earlier in 2022. He attempted to take his own life in July and was detained in hospital. The family expected a longer admission but he was discharged after four weeks, against their wishes. The inquest heard the ward had no psychologist in post during his stay.
A consultant psychiatrist told the court that stability on the ward, including the absence of self‑harm, contributed to the discharge decision. The coroner found the discharge plan relied excessively on the family to monitor relapse and medication without adequate support, noting it was unlikely Mr Stone‑Houghton was taking antipsychotic medication at the time of the deaths.
Community clinicians twice requested Early Intervention in Psychosis (EIP) support after discharge. Both referrals were rejected because the trust’s EIP service had a 65‑year age cut‑off. Mr Stone‑Houghton was instead placed on a waiting list of around a year for specialised talking therapy.
The contingency plan centred on relatives alerting the crisis team if deterioration occurred. No formal carer’s assessment was recorded for his wife, Ruth, 60, who was providing day‑to‑day care. Under the Care Act 2014, local authorities must assess carers who appear to have support needs; the inquest heard no such assessment had taken place.
Oliver and Abbie Stone‑Houghton said their parents were loving and devoted, and that they do not blame their father. Oliver told the BBC he never viewed the events as anything other than the effects of severe illness. The coroner also described the couple as loving and happy.
For providers, the findings point to well‑known failure points in discharge from acute psychiatric care: clear medication adherence plans, access to psychological input on wards, and timely, needs‑based community follow‑up. Where families carry significant responsibility, they require structured guidance, written relapse plans and defined escalation routes.
Age‑restricted access to EIP was a decisive barrier in this case. Commissioners and trusts may wish to review whether local criteria, capacity and referral pathways exclude older adults who otherwise meet clinical thresholds, and whether alternative pathways can offer an equivalent rapid response where EIP is not available.
On carer involvement, providers should document how responsibilities are shared, prompt statutory carer assessments with the local authority where appropriate, and ensure families receive medication information and contact details for urgent advice. These measures reduce the risk of unmanaged relapse in the community.
Hampshire and Isle of Wight Healthcare NHS Foundation Trust expressed condolences and said it had learnt from the case, committing to improve support for people in crisis and their families. Progress on discharge protocols, EIP access criteria and waiting‑time performance will be watched closely across the local system.