Family say Southampton dad Sasha Taylor who died of an overdose was failed by Southern Health Trust

Sasha Taylor, from Southampton, died at Southampton General Hospital after suffering a fit.

The inquest heard that in the year before the 49-year-old’s death, the levels of his prescribed drugs were higher than the recommended maximum guidelines.

Mr Taylor’s family believe that the effects of these drugs should have been monitored by Southern Health. They are also angry that his medication was changed during a telephone conversation with his psychiatrist.

Giving evidence at Winchester Coroner’s Court, his partner Sharon Bonsteel said that Mr Taylor, who lived in Lower Alfred Street, had appeared to be “slowing down” in the months before his death.

She found him having a seizure at her home on July 26. He was rushed to Southampton General Hospital but doctors were unable to save him.

The inquest heard the 49-year-old suffered from symptoms of psychosis and was an alcoholic who told doctors he was “dry” in April last year.

In December 2015, the inquest heard, Mr Taylor overdosed on prescribed drugs, and he told doctors he had also suffered seizures in the past – but his family were not aware of this.

The court heard that Southern Health put him above the recommended limits of medication to “support” Mr Taylor with his psychosis.

Dr Guy Roberts, a psychiatrist for Southern Health, was responsible for Mr Taylor’s care from November 2015.

Dr Roberts told the court Mr Taylor failed to turn up to an appointment on July 12, and he chose to phone him and change his medication.

Dr Roberts said he wanted to eventually lower Mr Taylor’s levels back down to the recommended limits, but in order to do this would briefly raise the level of olanzapine.

Dr Roberts said: “I have thought long and hard about what we could have done differently for Sasha and I think the high dose of anti-psychotic drugs may have been incidental.

“The patient appeared to have taken more than his prescription dose of medication and the reasons he has done that remain unclear.”

The court heard he died of mixed drugs toxicity; he had toxic levels of two anti-psychotic drugs and a raised level of an anti-depressant.

The major finding was a high level of amisulpride, an anti-psychotic drug, which was 15 times more than the recommended level for therapeutic use.

Senior coroner Grahame Short recorded a verdict of a drugs-related death.

Mr Short said: “It is right to say that whatever the high levels of drugs which were prescribed, that those did not in themselves lead to his death.

“But it is worrying for us to learn that these high levels of anti-psychotic drugs, which can have serious side effects, were not monitored over 12 months.”

The family of Mr Taylor were critical of Southern Health NHS Foundation Trust.

They say that Mr Taylor’s prescription drugs should have been monitored, and that Dr Roberts should not have changed his medication over the telephone.

After the hearing, Mr Taylor’s sister Lara Taylor-Jenkins said: “We think the medication should not have been done over the telephone and there were no checks carried out on him.

“Why when he was on an already dangerous level would someone increase that?”

Southern Heath response

An report by Southern Health revealed that this is the second "serious investigation" taken by the trust about the use of high dosage anti-psychotic medication.

Since then the trust has carried out an audit of patients on high doses and is now putting in place plans to improve their practices.

Clinical director for mental health at Southern Health NHS Foundation Trust, Professor David Kingdon, said: “I was very saddened to learn that Sasha had died and I have recently met with his family to offer my condolences.

“As soon as the team supporting Sasha became aware he was on a high dose of medication they put a plan in place to adjust this so it was still providing effective treatment whilst minimising possible side effects. We worked hard to reach Sasha to discuss these changes and our plan to help manage the transition.

“We have carried out our own internal investigation and made a number of improvements to the way we support people on higher doses of medication.

"For example, all our teams now have a nominated physical health lead to monitor the physiological effects of psychiatric mediation, and a review of patients receiving high-dose therapy now takes place at every clinical team meeting."