The death of a much-loved Chesterfield father on Boxing Day 'would have been avoided' had he not been discharged from the town's Hartington Unit with prescribed medication, a coroner has concluded.
Kevin Burton - who had a history of mental health issues and drug abuse - was found dead at a Chesterfield bed and breakfast after overdosing on his prescribed medication and illegally-obtained substances.
Last week, Chesterfield coroners' court heard the 47-year-old was admitted to the Morton ward on the Hartington Unit in early December 2015 after an attempted drug overdose and was discharged on December 22 with four days' worth of medication.
Concluding that Mr Burton died by suicide, coroner Peter Nieto told the court: "Mr Burton died in temporary bed and breakfast accommodation on December 26, 2015.
"He died due to the combined toxic effects of taking his prescribed medication and illicitly-obtained substances.
"He had been discharged from an inpatient mental health admission four days previously and he had mental health and substance misuse problems.
"In view of the large overdose he took and the fact that he left farewell notes which read as suicide notes, and that these were near to him when his room was entered, it is found that on the balance of probabilities he had undertaken a deliberate act with the intention of taking his own life."
Mr Nieto added: "Mr Burton's death due to suicide was contributed to by his very recent hospital discharge and supply of prescription medication which he took in combination with other substances and which resulted in the fatal overdose and led to his death due to their synergestic toxic effects.
"Although the discharge decision appeared to be a clinically valid decision, on the evidence and on the balance of probabilities, his death on December 26, 2015, would have been avoided had he not been discharged on December 22, 2015, with possession of the prescribed medications."
At the beginning of Mr Burton's inquest, Kathleen Jones said she told Dr Simon Taylor, a consultant psychiatrist at the mental health facility, that her brother would 'kill himself' if he was discharged.
Dr Taylor said 'on a clinical level, there was no reason for him to be on the ward'.
The court also heard evidence from Dr Sugato Sarkar, who conducted an investigation on behalf of Derbyshire Healthcare NHS Foundation Trust following the death of Mr Burton, whose usual address was Danby Avenue, Old Whittington.
But Dr Chris Kelly, who was instructed by the coroner to carry out an investigation into Mr Burton's death, told the court: "In my view, it was risky to give him four days' worth of (medication)."
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