The family of a Northampton man who died of an accidental overdose has paid tribute to a “brave and courageous son and brother”.
Berry Djebli, 43, was found dead from “a cocktail of his own medication” in his care flat in Spencer Street in February 2016.
But an inquest into his death (November 8) heard how Berry had been discharged from Berrywood mental health hospital, in Duston, just four days earlier without his family being told.
Coroner Jacqueline Devonish scolded Berrywood for sending the patient on his way at 4.30pm on a Friday and leaving “no time” to make proper arrangements for his care.
She said: “If [Berry] hadn’t been released from hospital, would he still be alive? The answer is probably yes.
"The decision to discharge was the wrong decision for Berry."
Four days before he died, Berry was discharged from Berrywood at 4.30pm on a Friday after an incident where he tried to kick down a staff door.
The duty psychiatrist at the time, Dr Krishna Yathiraj, said: “Please understand that [that Friday afternoon] was a crisis on the ward. I had to make a decision. I believed he was fit for discharge.”
Four days later, Berry was found dead in his flat at William Tarry House, in Spencer Street.
The coroner ruled that Berry had “adjusted” his medicine after sensing he was becoming unwell and overdosed.
She also found William Tarry “missed opportunities” to check in on him.
Berry’s family said in a statement: “We have lost a son and a brother who was loved and will be missed by all that knew him. Berry was brave and courageous in fighting his illness during his life.
“The family’s sincere hope throughout the inquest process was that changes would be made and lessons learnt to help ensure such a loss would not happen again.”