Rory Attwood

On 11 /10/2018 an investigation was opened into the death of Rory Karl Attwood DOB 28/6/96 The investigation concluded at the end of the inquest on: 3/11/2020 The conclusion of the inquest was recorded as: Suicide The medical cause of death was: 1a) Acute Methylenedioxyamphetamine (MDMA) Toxicity

Rory Attwood had a history of mental health problems. On 27 July 2018 Rory jumped from Union Street bridge in Newport, South Wales and injured his legs. He underwent a psychiatric assessment at which time he denied any suicidal attempt and that he had slipped when drunk. A further assessment revealed that whilst Rory had no obvious immediate suicidal intent, of concern was the fact that he showed no remorse for his actions. On 3111 August Rory discharged himself from hospital. He underwent a social care assessment at which time it was confirmed that Rory needed to he re-homes but there was no further involvement in Rory's care from the adult Disability team. Furthermore Rory was not followed up by community mental health teams.

It is obvious that Rory was vulnerable and yet there was no statutory monitoring arranged because he did not fall squarely into a box of social, physical or mental health. Rory continued to ruminate over ending his life. At about 5am on 9/10/18. Rory's father entered his son's bedroom and discovered that Rory had died. Emergency services were called but Rory could not be revived and the paramedics confirmed his death at 05:25 hours. A post mortem examination concluded that Rory had suffered an acute cardiac event and that Rory had in his blood f MDMA normally consumed for recreational purposes. In the absence of any underlying cardiac pathology the pathologist's opinion was that the cardiac death has on balance been caused by the consumption of an excessive quantity of MDMA. Following the inquest an internal investigation was undertaken, by Aneurin Bevan University Health Board and recommendations were made in relation to more cohesive working practices between partner agencies. At the inquest Rory's General Practitioner, Dr gave evidence. He was asked about how practices had changed since Rory's death. Dr admitted that General Practitioners rarely (and he has never been) invited to participate in a Serious Untoward Incident Review when a community patient has died. 5 CORONER'S CONCERNS During the course of the inquest, evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: - The purpose of undertaking a Serious Untoward Incident Investigation, is to identify necessary organisational changes which can improve the outcomes for patients and hopefully prevent future deaths. Rory had been discharged from acute services and was under the care of his General Practitioner. In keeping with many people he had been involved with different arms of ABUHB (primary, acute and psychiatric) He had been involved with social services. After his death the charity MIND wrote to me and expressed concerns that Rory had fallen between gaps in services. This was addressed in the internal investigation undertaken by ABUHB, however it is surprising that his GP was not involved in this review and Dr e told me that GPs are rarely asked to participate in these investigations. In order that lessons can be learned and opportunities identified for better partnership working around patients, it would seem appropriate that the patient's primary care contact (especially when being supervised in the community) be involved in internal /serious incident reviews.

I should be grateful if the following information be provided to me: Confirm whether it is your intention to review the current process of serious incident investigation and ensure that General Practitioners (and indeed any other relevant third party agencies) are to be routinely involved in serious incident reviews in the future.