A "much loved" father of two who lived with chronic pain for 5 years after falling three storeys from a window and was found dead at his parents' home died through misadventure, a coroner has ruled.

Edward Jorge Capovila, 41, of Gloucester Street, Barrow, was found dead by his father, Jorge Capovila senior, at 11.30 am on October 30, 2020, shortly after his discharge from his inpatient stay at the Dova Unit, an acute mental health unit at the Dane Garth site of Furness General Hospital.

Coroner Ms Kirsty Gomersall heard that Mr Capovila was severely affected by the death of his aunt in 2016, an incident with directly led to Mr Capovila falling from a third-storey window, an event that led to him suffering a lot of pain thereafter. 

He was prescribed medication for this and also for schizophrenia, which he was also diagnosed with, and was engaged throughout this time with mental health services.

The inquest heard that multiple drug toxicity of prescription drugs was the medical cause of Mr Capovila's death, with neither suicide nor third-party involvement being a factor.

An internal Lancashire and South Cumbria NHS Foundation Trust investigation found that there were potential issues with the handling of Mr Capovila's discharge, with his mother felt was too early.

Among these were that Mr Capovila's parents were not invited to the meeting about his discharge, which the Trust admitted was 'an oversight' and apologised for, and that his parents were not informed of their right to request a mental health assessment for Mr Capovila.

The coroner ultimately ruled that while the Trust's actions were 'not necessarily acceptable', they did not directly cause the death of Mr Capovila.

The inquest heard that the Trust has now made changes to their procedure of dispensing medication as a direct result of the circumstances of his death, and Mrs Tara Gallagher, Senior Pharmacist for the Trust, addressed his parents: "I hope you can see from the level of consideration and preparation and action taken that Eddie's case for me will never be forgotten".

In conclusion, Ms Gomersall said: "Eddie was the much-loved father of two girls, he was a beloved son, and adored brother and grandson, member of a wide and loving family.

"He was intelligent and he was handsome.

"His two daughters are still coming to terms with the loss of their father."