Family Alleges NHS Failures Preceded Son's Tragic Death
The devastated family of a man who took his own life have stated he was profoundly 'let down' by National Health Service providers. Jordon 'Jord' Copestake, who struggled with emotionally unstable personality disorder and post-traumatic stress disorder, was discovered deceased inside his Audi A4 on Pitsford Street in Longton on December 28, 2024.
Inquest Reveals Care Pathway and Prescription Concerns
A formal inquest has been informed that the NHS initiated a healthcare review following the death of the 32-year-old. His father expressed that Jordon was 'poorly treated' prior to his passing and should not have been granted access to a high volume of medication. Significant questions were raised regarding whether mental health teams responded adequately after Jordon disclosed plans to end his life.
In an emotional statement, his father said: “We feel our son was poorly treated and he was brainwashed. We accept he made a few wrong decisions, which we were not made aware of by the healthcare workers, or those who called themselves his friends. We would like to know why he was prescribed so many tablets with many side effects. In our opinion, surely you shouldn’t be driving on all those different tablets. He was left to his own devices. Healthcare workers had no idea what was happening. We feel let down.”
Detailed History of Mental Health Engagement
Jordon was initially referred to the Sutherland Centre in August 2020 after reports of self-harm thoughts. He was next seen in March 2023 following an alleged overdose attempt. A diagnosis of emotionally unstable personality disorder and PTSD was confirmed in June 2024. Consultant Psychiatrist Dr Uzma Saeed, overseeing his care, told the inquest he struggled with ongoing suicidal thoughts and emotional regulation, exhibiting symptoms like flashbacks, hypervigilance, social anxiety, and hallucinations.
In March 2023, during a mental health crisis, he was prescribed long-term mirtazapine and a two-week course of diazepam—an addictive anxiety medication intended for short-term use. Jordon later discontinued mirtazapine but continued using 'street diazepam' after his prescription lapsed. He was referred back to the Sutherland Centre in February 2024 after staff at the Stoke-on-Trent Community Alcohol & Drug Service noted concerns related to his diazepam use.
Private Therapy and Missed Interventions
By June 2024, Jordon began seeking private therapy. His counsellor alerted the Sutherland Centre in November after he revealed detailed suicide plans, stating he intended to overdose in his car if not better by a certain date. Despite this breach of confidentiality to warn mental health staff, Jordon was not admitted to psychiatric care. Dr Saeed explained the clinical team employed a 'structured boundary approach,' believing hospitalisation would not guarantee safety and that he retained full capacity and understanding of his treatment.
Staff conducted welfare checks, and Jordon did not act on his planned date of December 22. However, he missed appointments on December 18 and 23. After a therapy session on December 24 where he reported low mood without active suicidal ideation, his counsellor grew concerned by December 26 due to lack of communication and contacted Staffordshire Police.
Discovery and Official Findings
PC Michelle Morley located Jordon's vehicle on Pitsford Street in the early hours of December 28. After forcing entry, CPR was performed, but paramedics pronounced him dead at 2:38 AM. Dr Terry Jones confirmed the cause as a drug overdose. A patient safety review by Craig Stone of North Staffordshire Combined Healthcare NHS Trust concluded staff had acted appropriately, noting Jordon was on the correct assessment pathway but never reached the treatment threshold before his death.
Coroner Lindsey Tonks ruled the death a suicide, offering deepest condolences to the family. She did not issue a prevention of future deaths report, stating she was satisfied Jordon intended to end his own life when he consumed the medication in his locked car.
