Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0240, written 21 May 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 May 2025 |
|---|---|
| Reference | 2025-0240 |
| Deceased | Robert Smith |
| Coroner | Andrew Morse |
| Coroner area | South Wales Central |
| 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.
GRAEME HUGHES HIS MAJESTY’S SENIOR CORONER SOUTH WALES CENTRAL CORONER AREA CORONER’S OFFICE THE OLD COURTHOUSE COURTHOUSE STREET PONTYPRIDD CF37 1JW Telephone: 01443 281100 Email: ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive Cardiff & Vale University Health Board CORONER I am Andrew Morse H M Coroner, for the coroner area of South Wales Central. 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 30 October 2023 I commenced an investigation into the death of Robert Maxwell SMITH . The investigation concluded at the end of the inquest 07/05/2025 . The conclusion of the inquest was Suicide. 1a Pressure On Neck, Consistent With Hanging 1b 1c II CIRCUMSTANCES OF THE DEATH: Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862 1 2 3 4 These were recorded as follows Robert Maxwell Smith died on 26th October 2023 at died by hanging , Cardiff. Mr Smith . It is more likely than not that he intended the consequences of his action to result in his own death. Mr Smith had recent contact and intervention from mental health services and was known to be at risk of suicide due to a deterioration in his mental health presentation over the preceding weeks. Mental heath services did not inform Mr Smith’s wife of the extent of his suicidal ideations. Mr Smith had indicated that he would inform his wife of his raised suicidal ideations but did not do so. On balance, it cannot be said that if such information had been provided, Mr Smith’s suicide would have been prevented. Conclusion: Suicide 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. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 1. The guidance provided to clinicians and nursing staff within the mental health services as to when information and sharing and information gathering was to be undertaken with, and from, family members and how such decisions are to be recorded on the standard forms lacked clarity, particularly as regards the distinction between information sharing and information gathering. Such guidance being of relevance when a patient has given consent for information sharing and gathering to take place and when, and in what circumstances, such steps would be taken. 2. The information leaflet provided to patients lacked sufficient detail of the approach taken by mental health services on the issue of information sharing and information gathering so that patients could readily understand the difference between the two and understand when the need for information sharing and/or gathering could arise and what steps would be taken by mental health services. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. 5 6 7 YOUR RESPONSE Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862 You are under a duty to respond to this report within 56 days of the date of this report, namely by 16th July 2025. Only I, the Coroner, may extend the 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 proposed. COPIES and PUBLICATION I have sent a copy of my report to family who may find it useful or of interest. HeaIth inspectorate Wales, Welsh Government, 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 or 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. 21 May 2025 SIGNED: Andrew Morse H M Coroner for South Wales Central Coroner Area 8 9 Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862
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.
Executive Headquarters / Pencadlys Gweithredol
Woodland House
Maes-y-Coed Road
Cardiff
CF14 4HH
Ty Coedtir
Ffordd Maes-y-Coed
Caerdydd
CF14 4HH
Chief Executive
Eich cyf/Your ref:
Ein cyf/Our ref: SR-jtf-0725-118
Welsh Health Telephone Network:
30 November 2022
Direct Line/Llinell uniongychol: 029 2183 6010
10 July 2025
Mr Andrew Morse
Coroner’s Office
The Old Courthouse
Courthouse Street
Pontypridd
CF37 1JW
Sent via email
Dear Mr Morse
Re: Regulation 28 Report to Prevent Future Deaths – Robert Maxwell Smith
Thank you for your report dated 21 May 2025 concerning the tragic death of Mr.
Robert Maxwell Smith. We acknowledge the concerns raised during the inquest and
are committed to taking appropriate actions to prevent future occurrences.
Response to Coroner’s Concerns:
Guidance on Information Sharing and Gathering:
We recognise the need for clearer guidance for clinicians and nursing staff regarding
information sharing and gathering with family members. During June and July 2025,
we have worked with families, carers, service users and clinicians to co-produce
values-based guidance to ensure that the distinction between information sharing
and information gathering is clearly defined and understood. The guidance will
include examples of lived experience in the form of quotes from families and service
users and will include detailed instructions on when and how to document these
interactions on standard forms.
Patient Information Leaflet:
We agree that the current patient information leaflet lacks sufficient detail on the
approach to information sharing and gathering. During June and July 2025, we have
worked with families, carers, service users and clinicians to co-produce a leaflet
which will provide comprehensive information so that patients can easily understand
the differences and the circumstances under which information sharing and
gathering will occur. This will help ensure that patients are fully informed about the
Bwrdd Iechyd Prifysgol Caerdydd a’r Fro yw enw gweithredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro
Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Health Board
Croesawir y Bwrdd ohebiaeth yn Gymraeg neu Saesneg. Sicrhawn byddwn yn cyfathrebu â chi yn eich dewis iaith. Ni fydd gohebu yn Gymraeg yn creu unrhyw oedi
The Board welcomes correspondence in Welsh or English. We will ensure that we will communicate in your chosen language. Correspondence in Welsh will not lead to a delay
processes and their rights. We recognise that families, carers, and significant others
often play a key role in service users care and we are therefore also developing a
family and carer information leaflet.
Action Plan:
Revision of Guidance:
We have established a working group with involvement from families, carers, service
users and clinicians to review and revise the existing guidance. The revised
guidance will be disseminated to all relevant staff members through training sessions
and internal communications. We aim to complete this process by October 2025.
Updating Patient Information Leaflet:
The updated leaflet will be developed by a panel of experts, including mental health
professionals, families, carers, and service users, to ensure that it is values based,
has clarity and is comprehensive. We plan to have the new leaflet available for
distribution by October 2025.
Training and Awareness:
We will conduct mandatory training sessions for all mental health service staff to
ensure they are fully aware of the revised guidance and the importance of accurate
documentation. These sessions will start in October 2025.
Information Sharing and Suicide Prevention:
We have included information regarding the UK Government, Department of Health
information sharing and suicide prevention: consensus statement" within the
guidance. This statement emphasises the importance of sharing information within
the context of relevant laws and professional judgment to prevent suicide.
Communication to Managers and Staff:
We will discuss the theme of information sharing and gathering at the MHCB (Mental
Health Clinical Board) Professional Learning Event and Shared Learning Event in
September 2025.
Co-produced Family Engagement Project:
The Mental Health Clinical Board has commissioned a co-produced family
engagement project. This project started in May 2025 and aims to support a cultural
shift in practice to enhance family engagement and involvement. The project will
complement existing initiatives across the Mental Health Clinical Board which
prioritise and encourage family engagement, particularly those based on co-
productive and compassionate care. Due to the nature of co-production work, whilst
there is an anticipated time of two years for the project, this needs to be agreed with
the project working group.
Bwrdd Iechyd Prifysgol Caerdydd a’r Fro yw enw gweithredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro
Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Health Board
Croesawir y Bwrdd ohebiaeth yn Gymraeg neu Saesneg. Sicrhawn byddwn yn cyfathrebu â chi yn eich dewis iaith. Ni fydd gohebu yn Gymraeg yn creu unrhyw oedi
The Board welcomes correspondence in Welsh or English. We will ensure that we will communicate in your chosen language. Correspondence in Welsh will not lead to a delay
We are committed to implementing these changes promptly and effectively to
enhance the safety and well-being of our patients. We will provide a detailed update
on the progress of these actions by the deadline of 16 July 2025.
Thank you for bringing these critical issues to our attention. We are dedicated to
improving our services and preventing future tragedies.
Yours sincerely
Chief Executive
Bwrdd Iechyd Prifysgol Caerdydd a’r Fro yw enw gweithredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro
Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Health Board
Croesawir y Bwrdd ohebiaeth yn Gymraeg neu Saesneg. Sicrhawn byddwn yn cyfathrebu â chi yn eich dewis iaith. Ni fydd gohebu yn Gymraeg yn creu unrhyw oedi
The Board welcomes correspondence in Welsh or English. We will ensure that we will communicate in your chosen language. Correspondence in Welsh will not lead to a delay
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