Jason White: Prevention of future deaths report

Suicide (from 2015)

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Date of report: 19/12/2025

Ref: 2025-0638

Deceased name: Jason White  

Coroner name: N Mundy

Coroner Area: South Yorkshire East
 
Category:  Suicide (from 2015) 
 
This report is being sent to: Sheffield Health Partnership, University NHS Foundation Trust

REGULATION 28 REPORT TO PREVENT DEATHS
THIS REPORT IS BEING SENT TO:

Sheffield Health Partnership, University NHS Foundation Trust
1CORONER

I am Ms N J Mundy for South Yorkshire East
2CORONER’S LEGAL POWERS

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and  regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 
3INVESTIGATION AND INQUEST

On 20 December 2024 I commenced an investigation into the death of Jason Ricardo White.  The investigation concluded at the end of the inquest . The conclusion of the inquest was  Suicide. 
The cause of death was:   
1a                  [REDACTED] 
 
4CIRCUMSTANCE OF THE DEATH

Jason Ricardo White developed mental health symptoms in April 2024 which were essentially  depression and psychotic episodes. Mr White engaged with both his GP and mental health  support services including the Priory hospital in Nottingham, Sheffield Teaching Hospitals NHS Trust, Sheffield Health Partnership University NHS Foundation Trust, and Sheffield City Council to manage his symptoms. He remained fixated on his symptoms being linked to serious medical complaints and appeared at no time to accept that the physical symptomology of which he complained was inextricably linked to his mental health challenges.  Mr White received  various levels of management which included medication. One of those medications was  olanzapine. This was ceased abruptly due to a belief that this was responsible for deranged  liver function tests but there was inadequate follow-up thereafter. As it was Mr White died from [REDACTED] on the 10th of December 2024 [REDACTED]                                                                                  .   
5CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern. In my  opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. 

During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstance it is my statutory duty to report to you.
6ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe you, (and/or your organisation) have the power to take such action. 

The MATTERS OF CONCERN are as follows. – 
1. Antipsychotic medication (Olanzapine) abruptly ceased and the management plan of daily  monitoring was not followed. 
2. This created a risk of relapse in terms of psychotic symptoms and associated deterioration 
in mental health.   
3. Risks of relapse when any medication is abruptly ceased. Must be fully monitored; the  absence of full assessment and monitoring exposes patients to risk of a serious deterioration in mental health.   

In my opinion action should be taken to prevent future deaths and I believe you, [REDACTED] have the power to take such action. 
  
7YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely  by the 13th February 2026. I, the coroner, may extend the period. 
Your response must contain details of action taken or proposed to be taken, setting out the  timetable for action. Otherwise you must explain why no action is proposed. 
8COPIES AND PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 
[REDACTED], Sheffield City Council and Priory Healthcare.    
I am also under a duty to send the Chief Coroner a copy of your response. 
The Chief Coroner may publish either or both in a complete or redacted or summary form. He  may send a copy of this report to any person who he believes may find it useful or of interest.  You may make representations to me, the coroner, at the time of your response, about the  release or the publication of your response by the Chief Coroner. 
9Ms N. J . Mundy LL.B (hons)   
Senior Coroner for South Yorkshire East