Source · Prevention of Future Deaths

Connor Davies

Ref: 2019-0412 Date: 29 Nov 2019 Coroner: Geraint Williams Area: South Wales Central Responses identified: 1 / 1 View PDF

Repeated cancellation of consultant psychiatrist appointments without clinical input on patient urgency meant individuals at serious need could "fall through the net," as a preventative system was not yet operational.

Date 29 Nov 2019

56-day deadline 23 Feb 2020 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths Suicide (from 2015) Wales prevention of future deaths reports (2019 onwards)

Coroner's concerns

AI summary

View full coroner's concerns

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) Mr Davies was seen by a consultant psychiatrist in November 2018 and a follow up appointment made for January 2019. That appointment was cancelled and another made for March 2019. That too was cancelled and a further appointment made for June 2019 but before he could attend Mr Davies killed himself. who gave evidence confirmed that when appointments are cancelled there is no clinical input as to the need of individual patients for more urgent referrals and thus a patient who is in serious need of an appointment may ‘fall through the net’ as may have been the case here. told me that he had endeavoured to put in place a system whereby this could be avoided but, to his knowledge, it is not yet operating.

I recommend that your Trust consider this potential issue as a matter of urgency.

Responses

1 respondent

University Health Board

23 Jan 2020 PDF

Action Planned

The University Health Board has developed an action plan to address the matters raised during the inquest and all outstanding actions are being implemented by the Mental Health Directorate. (AI summary)

View full response

Dear Mr Hughes RE: Regulation 28 Connor Davies Thank you for the correspondence dated the Sth December 2019 in relation to the above Regulation 28, which details the areas of concern following the conclusion of the inquest held on the 29th November 2019 in relation to the death of Connor Davies: Please be assured that the Health Board has taken this matter extremely seriously ad an action plan has been developed to address the matters raised during the inquest: A copy of the action plan is attached. You will note that action to address the issues raised are currently ongoing: All outstanding actions are being implemented by the Mental Health Directorate, who will ensure that there is evidence to support the completed action plan which will be monitored through the Service and Health Board Governance structures: I sincerely hope that this information will reassure you that the Health Board has learnt important lessons from the investigation into the care provided to Mr Davies and that effective action is being undertaken to prevent further deaths. I would Iike to convey once again my deepest sympathy and sincere apologies to Mr Davies' family for the failings identified:

Report sections

Investigation and inquest

On 23/04/2019 I commenced an investigation into the death of Connor William DAVIES. The investigation concluded at the end of the inquest 29th November 2019. The conclusion of the inquest was On the 13th April 2019 Mr Davies, who had been receiving assistance from Mental Health Services, hanged himself at 11 The Greenways, Maesteg. Cause of death: Hanging, Verdict: Suicide

Circumstances of the death

Deceased last had contact with family 10.4.19. He was seen by his grandfather around 0800 hrs 10.4.19. Today, 13.04.19 deceased's brother has decided to look for Connor as he was becoming concerned for his welfare. Brother and mother attended at 11 The Greenway and gone upstairs. Brother has opened a bedroom door to find deceased sat against a wall with a ligature around his neck. His backside was suspended off the floor, hands were in his pockets, his head was slumped to the right and his tongue was sticking out. Brother has shut the door and told his mother to and ring an ambulance. He has then gone back into the bedroom and removed the ligature from around his brother's neck, laid him onto his back on the floor. He felt for a pulse but could not find one. Ambulance crew arrived.

Copies sent to

I am also under a duty to send the Chief Coroner a copy of your responseSignature (electronic)Geraint Williams Assistant Coroner South Wales Central

Similar PFD reports

Shared signals

Related inquiry recommendations

Similar themes

Muckamore Abbey Inquiry Access to mainstream mental health services

Report details

Reference: 2019-0412
Date of report: 29 November 2019
Coroner: Geraint Williams
Coroner area: South Wales Central

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 23 Feb 2020 (estimated).

Sent to

Cwm Taf Health Board

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.