Mother of ‘lovely’ Nottinghamshire man who died of overdose urges GPs to meet patients face-to-face

Mother of a “cute” and “funny” the Nottinghamshire man who overdose prompted family doctors to meet face-to-face with patients suffering from mental health problems. Oliver Cass, 22, who had a long history of serious mental health problems, was found unresponsive by his mother at his home in Fairway, Keyworth, on June 12 last year.

He was found next to drug paraphernalia and pills, an inquest at Nottingham Council House in Old Market Square was told on Monday, June 22. At the inquest, Assistant Coroner Nathanael Hartley explained that he will question the health workers who treated Oliver and examine evidence to understand how the young man came to his unnatural death.

Oliver had been on anti-depressants since the age of 14 and suffered from anxiety, depression and insomnia. He self-harmed, drank alcohol and took drugs to try to cope with the immense emotional turmoil he had felt throughout his life, the inquest was told.

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From early 2022 until his death in mid-2023, he received treatment from his GP, therapists from Nottinghamshire Healthcare Trust and specialists from the trust’s crisis team. The inquest was told Oliver’s family had concerns about the consistency and type of care provided by Village Health Group in Keyworth.

Dr Gurvinder Sahota, a GP at the practice, explained that he became involved in Oliver’s care in June 2022. He took over from another GP who had left the practice, although there was a period in between when the 22-year-old was seen by a number of different doctors.

At the hearing, Oliver’s mother, Karen, had suggested that telephone meetings were not effective in understanding the true mental state of a patient like her son. Dr. Sahota, while admitting he had never met Oliver in person, said: “(While) you may miss body language, I think when it comes to mental health, it’s very individual to the person.”

While Dr Sahota said he formed a good relationship with the “polite” and “very nice” Oliver, his mother urged the doctor to hold face-to-face meetings with mental health patients in the future. “With what comes with mental health issues, you can talk and act one way but feel completely different and he was very good at that,” she told the inquest.

“One thing to take away from this is that it’s very, very important to see them face to face. You can tell by looking at them if they’re having a good day or a really bad day.”

Oliver’s family claimed they were “left hanging” by the lack of a GP Oliver could see consistently before Dr Sahota became his regular doctor, having to explain the situation several times to different doctors. The inquest was also told by his relatives that the receptionists were hanging up when a panicked and anxious Oliver said “I just want to see a doctor”.

Dr Sahota said he was not aware of any reception issues but pledged to review face-to-face appointments following Oliver’s death, adding: “We will take it to the clinic appointment and discuss this.

“I’ve gone over (his treatment) in my head several times – if there’s anything to learn, we’ll learn.” The coroner also heard evidence from therapist Abigail Graves, who helped Oliver in group therapy at Nottinghamshire’s mindfulness-based treatment service at the Mandala Center in Nottingham.

Ms Graves explained that he had always engaged well with the sessions, even though they had left him emotionally drained, and explained that she believed he was in a “hopeful place” at a session on June 8, 2023 – with just a few days before his death. When coroner Mr Hartley asked the family if they believed Oliver had intended to take his own life when he overdosed on June 12, they insisted he had not, with his mother adding: “He was a nice, funny and handsome man. he was ready to try anything to improve and he wanted to finish college.”

Oliver’s father and brother added that he was “very intelligent” and devoted to his friends and family. Based on the family’s views, the fact that police officers found no suicide note at the scene of his death and the apparent signs of improvement before his death, Mr Hartley concluded: “I do not find that Oliver intended to take his own life, I I accept, in fact, that this was accidental.”

The coroner agreed the cause of death post mortem was “combined drug toxicity”, before classifying the death as “drug related” rather than suicide. Despite the family’s concerns about Oliver’s lack of face-to-face time with Dr Sahota, Mr Hartley said: “I find Dr Sahota’s treatment decisions to be appropriate in the circumstances.”

He added that it was “only fair” that Nottinghamshire Healthcare Trust’s crisis team released Oliver before his death as he appeared to be making progress and was therefore at less risk. Mr Hartley closed the inquest by offering his condolences to Oliver’s family at the hearing, as well as other relatives and friends who were not present.