A SUICIDAL man died after a GP surgery gave him double the recommended dose of sleeping pills, an inquest heard.

Darren Carrington was found unconscious by his boyfriend Dr David Denton at their home in Brunswick Terrace, Hove, having taken a cocktail of prescription drugs.

The 39-year-old had made two suicide attempts in the two months before, and was depressed following the news of his mother developing Alzheimer’s disease and being put in a nursing home, Brighton Coroner’s Court was told.

Mr Carrington, an artist, had been out drinking on the night of December 12 and arrived home at 3am, falling asleep in the living room and being discovered shortly before 8am.

Dr Denton waited one minute and 44 seconds before being connected to South East Coast Ambulance Service in an emergency call, the inquest heard.

But the responding paramedics went to the wrong address – Brunswick Square rather than Brunswick Terrace, meaning there was a nine-minute delay in getting to Mr Carrington.

He suffered a 35-minute cardiac arrest brought on by the drugs, which experts said must have been taken all together and about two hours before he was found.

Mr Carrington was known to suffer from depression, anxiety, insomnia, obsessive compulsive disorder (OCD) and was dependent on alcohol.

Coroner Veronica Hamilton-Deeley blasted a new system at the North Laine Medical Centre which saw him receive more than double the amount of Zopiclone he should have in less than two months.

From October 12, 2017 to December 8, he was given 133 Zopiclone tablets.

He should have only been given 55 pills of the Class C controlled drug, but different members of staff gave him more than he was supposed to receive.

Mr Carrington’s GP, Dr Michael Sharp, told the court the recommended dosage is no more than one per night.

But under a new system which came into play in about October time, patients can request more drugs electronically. And staff at the surgery in Gloucester Street, Brighton, continued to give him more – despite the fact it is flagged up when he has received his prescription. However, receptionists and doctors overrode the warning, the inquest heard.

He should have been given 14 pills every two weeks, but requested more regularly. The inquest at Brighton Coroner’s Court heard despite his two recent overdoses on his prescribed drugs, Mr Carrington’s prescriptions had not been reviewed by his GP.

Mrs Hamilton-Deeley said: “I found this was a missed opportunity for the GP to carry out a medication review.

“It would have been good practice to do so.

“This man had just taken a serious overdose of his prescribed medication.”

She branded it “a worry” that this error had happened.

Mrs Hamilton-Deeley also stressed the importance of having an efficient prescription system in place, particularly in Brighton “because we have so many vulnerable people”.

“Currently, from the point of view of drug-related deaths, I have more drug deaths per capita than most other coroners’ jurisdictions,” she said. “I want to prevent future deaths."

Dr Sharp, who had been Mr Carrington’s GP for 20 years, gave evidence at the inquest at Brighton Coroner’s Court. When the coroner asked him the chances of similar over-prescribing happening to others, he responded: “There is that risk, yes.”

He admitted the new system needs to be reviewed and said the issue has been discussed between staff.

Mr Carrington died at the Royal Sussex County Hospital in Brighton two days after he was admitted.

By the time he was discovered, it was too late to save him as even if there had not been a delay with the ambulance, the outcome would have been the same, the inquest heard.

He had traces of MDMA, Diazepam and amphetamine in his system as well as the high levels of Zopiclone. After the two-day inquest, coroner Veronica Hamilton-Deeley recorded Mr Carrington’s cause of death as respiratory failure caused by fatal levels of Zopiclone, codeine and alcohol.

This was brought on by a hypoxic brain injury due to cardiac arrest triggered by the combination of Zopiclone and codeine.

Mrs Hamilton-Deeley said Mr Carrington’s severe depression, anxiety and traits of personality disorder, as well his alcohol dependency syndrome and OCD, were contributing factors in his death.

The presence of alcohol, Diazepam, amphetamine and MDMA also played a part in Mr Carrington’s death.

Have you had suicidal thoughts? You can get help. Samaritans are available 24 hours a day, 365 days a year. Call 116123.