Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0270, written 31 Aug 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Aug 2022 |
|---|---|
| Reference | 2022-0270 |
| Deceased | Gareth Williams |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | Suicide (from 2015) · Wales prevention of future deaths reports (2019 onwards) · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1 2 3 1. The Chief Executive of Aneurin Bevan University Health Board (ABUHB) CORONER I am Caroline Saunders, Senior Coroner for the Area of Gwent CORONER'S LEGAL POWERS I make this report under Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 INVESTIGATION AND INQUEST On 2/9/2021 an investigation was opened into the death of Gareth WILLIAMS The investigation concluded at the end of the inquest on: 17/8/22 The conclusion of the inquest was recorded as: Suicide The medical cause of death was: la) Suspension by ligature 2 Tinnitus 4 CIRCUMSTANCES OF THE DEATH Gareth Williams was a 45-year-old man who had a history of sensorineural hearing loss and intermittent tinnitus dating back to 2005. He was also treated for depression and insomnia. In early 2021 the situation deteriorated. Gareth's tinnitus worsened but despite being thoroughly examined by the ENT team there was no physiological problem that could be treated. As a result, Gareth's mental health went into decline. He suffered worsening depression and was referred to the mental health team after he started having suicidal thoughts and indeed acting these out. Written evidence from the Consultant Psychiatrist treating Gareth, stated Gareth was not clinically depressed, although evidence also indicated that he had low mood, was expressing hopelessness and experienced suicidal thoughts. Gareth was discharged from the mental health team because he had no recognisable mental illness. On 23/8/21, Gareth was discovered hanging in Abergavenny. Emergency services attended but Gareth could not be revived. His death being confirmed at 15:27 hours. 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: - Gareth Williams found himself in a no-win situation. His mental health could not be improved without a resolution to his hearing problems and his tinnitus was untreatable. During the course of his treatment, Gareth was regularly transferred back to the "other" team, being told that either mental health or ENT was the most appropriate speciality. I found that Gareth was left without sufficient support, falling between 2 teams, who did not directly communicate with each other. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. I should be grateful if the following information be provided to me: Whether Aneurin Bevan University Health Board intend to undertake a review into the circumstances surrounding the death of Gareth Williams and confirm the steps which will be taken to ensure that there is better interdisciplinary working between physical and mental health specialities in the future. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 25/10/22. I, the Coroner, may extend this period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is necessary 8 COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) The family of Gareth Williams I am also under a duty to send the Chief Coroner a copy of your response. The Chief coroner may publish either or both in a complete or redacted summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Coroner, at the time of your response, about the release or the publication of your response by the Chief coroner. 9 DATE 31/08/22 Signed Caroline Saunders Her Majesty's Senior Coroner for the Area of Gwent.
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
9th March 2023
Private & Confidential
Caroline Saunders
Senior Coroner (Gwent)
Dear Ms Saunders
Re: Regulation 28 Report received by Aneurin Bevan University
Health Board further to the inquest touching on the death of Gareth
Williams concluded on 17.08.2022
I am writing to provide you with the Health Board’s response to the
Regulation 28 Report to Prevent Future Deaths, following the inquest into
the death of Mr Gareth Williams.
As requested, the information presented below is intended to describe the
action taken / being taken to mitigate the risk of future deaths.
You require the Health Board to provide you with the following information:
1. Whether the Health Board intends to undertake a review into the
circumstances surrounding the death of Mr Williams, and
2. Confirm the steps which will be taken to ensure that there is better
interdisciplinary working between physical and mental health
specialities in the future
A ‘concise review’ was undertaken by the Mental Health and Learning
Disabilities Division of the Health Board when we became aware of Mr
Williams’ death. Since that time, we have had the opportunity to review the
wider input of other specialties and understand what services might have
supplemented the offers of treatment and intervention available to Mr
Williams, in addition to the liaison with the ENT department undertaken by a
community mental health nurse with and for Mr Williams.
Bwrdd Iechyd Prifysgol Aneurin Bevan
Pencadlys,
Ysbyty Sant Cadog
Ffordd Y Lodj
Caerllion
Casnewydd
De Cymru NP18 3XQ
Ffôn: 01633 436700
E-bost: abhb.enquiries@wales.nhs.uk
Aneurin Bevan University Health Board
Headquarters
St Cadoc’s Hospital
Lodge Road
Caerleon
Newport
South Wales NP18 3XQ
Tel No: 01633 436700
Email: abhb.enquiries@wales.nhs.uk
Bwrdd Iechyd Prifysgol Aneurin Bevan yw enw gweithredol Bwrdd Iechyd Lleol Prifysgol Aneurin Bevan
Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board
The Health Board acknowledges that its organisational structure has
historically, not naturally lent itself well to easy and timely communication
between its multiple specialties and disciplines across the Divisions.
I am pleased to share that Welsh Government has confirmed that a Health
Board service - ‘Adferiad’ - originally developed for people experiencing the
effects of ‘Long Covid’ will be receiving substantive, recurrent funding from
April 2023 which will also allow it to broaden its inclusion criteria to people
with other medical and long-term conditions for whom there are no existing
care pathways. This service will be delivered by a team of medical, nursing
and Allied Health Professionals – including Health and Clinical Psychologists,
thus offering a multi-disciplinary perspective from the point of referral and
for consultation to other disciplines & specialties. Part of the expansion of
the service will be to map existing services to ensure the person is on the
‘right’ pathway, with a ‘bespoke’ approach to each person’s needs.
It is anticipated that people with co-morbidities and needs such as Mr
Williams could be referred to Adferiad. The new team will provide expertise
upfront in terms of assessment and planning care. The team would develop
an individualised recovery and rehabilitation plan with individuals.
I trust that this information assures you of the Health Board’s plans to
improve interdisciplinary working between physical and mental health
specialties in the future. If any further information or assurance is required,
please do not hesitate to contact me.
Yours sincerely
Prif Weithredwr/Chief Executive
2
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