Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0270, written 11 May 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 May 2026 |
|---|---|
| Reference | 2026-0270 |
| Deceased | Trevor Evans |
| Coroner | Gareth Lewis |
| Coroner area | Carmarthenshire and Pembrokshire |
| Source | judiciary.uk record |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REPORT TO PREVENT FUTURE DEATHS REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 Please do not include any living persons’ names in this document, in accordance with the Chief Coroner’s PFD Publication Policy (2026). 1. CORONER I am Gareth Lewis, Senior Coroner, for the coroner area of Carmarthenshire and Pembrokeshire. 2. DATE OF REPORT 11th May 2026 3. 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. 3. THIS REPORT IS BEING SENT TO 1. Hywel Dda University Health Board You are under a duty to respond to this report within 56 days of the date of this report, namely by 6th July 2026. I, the coroner, may extend the period if an appropriate application is made. 4. YOUR RESPONSE 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. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports - Courts and Tribunals Judiciary. 5. SUMMARY OF CORONER’S CONCERN During the inquest I heard evidence which concerns me about the approach taken by those undertaking mental health assessments within the Community Mental Health Team. Whilst I have received evidence from the Senior Nurse for Pembrokeshire Adult Community Mental Health Service to say that there is a more robust system in place now (compared to when Trevor died in 2020) and that there is an aide memoir which has been implemented to support practitioners to systematically collate the information required from referrers when receiving referrals for assessment, I still have concerns. The reasons for my concerns are that contrary to the above, I also received evidence during the inquest from a Community Psychiatric Nurse who said: “it’s not my job” to seek out information, “that is the duty of the referrer” and “the Role of the Duty Officer (i.e. the person doing the assessment) is to assess the information not gather it”. Furthermore the evidence of the Senior Nurse for Pembrokeshire Adult Community Mental Health Service was that “The process places emphasis on the referrer to provide a comprehensive and accurate handover. Responsibility for the accuracy and completeness of information provided, particularly in relation to identified or potential risks, rests with the referrer at the time the referral is made.” “There is no explicit requirement for the Community Mental Health Team to proactively seek information from partner agencies at the point of handover, unless the partner agency is the referring service.” For as long as that approach or attitude continues I fear that mental health risk assessments in Pembrokeshire may be incomplete, perfunctory and inadequate. There needs to be a change in culture to a more collaborative approach where those undertaking the assessment adopt a more inquisitive and information seeking style to ensure that as much relevant information as possible is available when undertaking these very important risk assessments. In this particular case, notwithstanding the fact that this was an emergency referral from a GP, the Risk Assessment was completed without knowledge of the significant police and ambulance involvement with Trevor in the preceding week, the fact that a noose had been found at Trevor’s home, his family were very concerned for his mental wellbeing, his previous suicide attempts and his previous involvement with the Crisis Response Home Treatment Team. There was an abundance of relevant information available had the assessor made some basic enquiries. There needs to be a shift of onus to a more collaborative approach so that those undertaking the assessment explore what information is available to them and do not simply rely on the details provided by the referrer. Ultimately, it is the assessors name on the risk assessment and they need to be satisfied that it is a thorough and robust assessment of the risk. 6. ACTION SHOULD BE TAKEN In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action. 7. INVESTIGATION AND INQUEST On 28th February 2020 an investigation into the death of Trevor Anthony Evans, aged 54 years, was commenced by the then Senior Coroner, Mark Layton. The investigation concluded at the end of a five-day inquest, heard by me, between 13th April 2026 and 17th April 2026. During the inquest I heard evidence allowing me to make the following findings: The medical cause of death was: Asphyxia by hanging How, when and where: Trevor Anthony Evans died as a result of hanging himself on 27th February 2020 Whitehall Drive, Pembroke in circumstances where he was struggling with his mental health and in the absence of a thorough mental health risk assessment being undertaken. at his home address of 37 Conclusion: Suicide 8. CIRCUMSTANCES OF DEATH [Please explain the relevant circumstances of the individual’s death, ideally this should be in no more than 500 words] During the inquest I heard evidence on events that occurred during the period 18th February 2020 through to the date of Trevor’s passing on 27th February 2020. The evidence focused specifically on Trevor’s contact with the police, ambulance service, mental health professionals and health care staff during that period. Trevor was struggling with his mental health during this period and his conduct was such that his family, the police and the ambulance service all had concerns for his mental health which culminated in a GP making an emergency referral for a mental health assessment. On 24th February 2020 Trevor was assessed by a Community Mental Health Nurse. After hearing evidence, I found that there was an over reliance on what Trevor told the nurse, a failure to review medical records and a lack of investigation or scrutiny into an abundance of background information that was available. With hindsight had all of that information which was readily accessible been reviewed then a referral to the Mental Health Crisis Team would have been appropriate. Trevor sadly took his own life on 27th February 2020. 9. CORONER’S CONCERNS During the course of the inquest I heard evidence giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: [250-word statement addressing what circumstances of the death have led to the coroner’s concern, and why the coroner thinks the person to whom the report is directed is responsible for taking action to prevent future deaths. This statement must not propose what action should be taken, as coroners cannot make recommendations]. In this case, I found that there was an over reliance on what Trevor told the nurse, a failure to review medical records and a lack of investigation or scrutiny into an abundance of background information that was available. Notwithstanding the fact that I have been told that changes have been made by the Health Board to ensure that those undertaking assessments now look to obtain as much information as possible I also received evidence which indicates that assessors still harbour an attitude that it is the referrer job to provide all the relevant information and then those performing the risk assessment will simply assess the information. For as long as that approach or culture continues I fear that mental health risk assessments in Pembrokeshire may be incomplete, perfunctory and inadequate. There needs to be a shift of onus to a more collaborative approach so that those undertaking the assessment explore what information is available to them and do not simply rely on the details provided by the referrer. It is essential that those undertaking the mental health assessments are aware of the need to obtain as much information as possible in order to complete a full and thorough assessment of the risk and that they are aware of how to and where to obtain the relevant information from. 10. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: [please do not use individual’s names, but instead roles/titles] 1. Family of Trevor Anthony Evans 2. Dyfed Powys Police 3. Welsh Ambulance Service Trust I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. SIGNATURE Gareth Lewis – Senior Coroner for Carmarthenshire & Pembrokeshire Dated: 11th May 2026
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.
Swyddfeydd Corfforaethol, Ail Lawr, Bloc C. Adeiladau’r Llywodraeth, Heol Picton, Caerfyrddin, Sir Gaerfyrddin, SA31 3BT Corporate Offices, Second Floor, Block C, Government Buildings, Picton Terrace, Carmarthen, Carmarthenshire, SA31 3BT Dyddiad/Date:6th July 2026 Mr Gareth Lewis Senior Coroner for Carmarthenshire and Pembrokeshire Coroner's Office North Wing, County Hall Haverfordwest SA61 1TP Dear Mr Lewis Response to the Report to Prevent Future Deaths issued on the 11th May 2026 Thank you for your correspondence dated 11th May 2026 concerning the above matter. I am writing on behalf of Hywel Dda University Health Board in response to the issues raised and to outline the actions taken and planned. The Health Board would like to thank the Coroner for bringing these matters of concern to our attention. We have carefully considered the findings arising from the inquest and sincerely acknowledge the concerns expressed regarding the quality of mental health risk assessment undertaken in this case and the need to ensure that practitioners adopt a collaborative, professionally curious and information-seeking approach when undertaking assessments. The Health Board accepts that effective risk assessment relies upon the gathering, consideration and formulation of information from multiple sources and should not rely solely on information provided by the referrer or by the individual being assessed. We recognise the Coroner's concern that an over-reliance on referral information could result in incomplete assessments and we are committed to ensuring our systems, training and culture support robust multi-agency information gathering and risk formulation. Actions already implemented Since the death of Mr Evans, the Health Board has implemented a number of improvements designed to strengthen information gathering, risk assessment and inter- agency communication. Ail Lawr, Bloc C, Adeiladau'r Llywodraeth Heol Picton, Caerfyrddin, SA31 3BT Second Floor, Block C, Government Buildings Picton Terrace, Carmarthen, SA31 3BT Bwrdd Iechyd Prifysgol Hywel Dda yw enw gweithredol Bwrdd Iechyd Lleol Prifysgol Hywel Dda Hywel Dda University Health Board is the operational name of Hywel Dda University Local Health Board Mae Bwrdd Iechyd Prifysgol Hywel Dda yn amgylchedd di-fwg Hywel Dda University Health Board operates a smoke free environment 1. Introduction of referral and assessment support tools A Comprehensive Assessment Tool has been introduced that requires practitioners to consider multiple sources of information, including historical and collateral information where available. The assessment includes prompts to seek information from family members, carers and other relevant sources, where appropriate and in line with consent, confidentiality and safeguarding requirements. This supports a more holistic understanding of an individual's presentation, circumstances and risks, and ensures collateral information is routinely considered in assessment, risk formulation and decision-making. The tool also enables practitioners to record the information sources used and any attempts made to obtain collateral information when it is unavailable. An aide memoir has been implemented to support practitioners in systematically gathering key information when receiving referrals for mental health assessment. This tool supports practitioners to obtain and document relevant information required to inform assessment and risk formulation. 2. Strengthened coordination and information sharing The Health Board has established an Out of Hours Clinical Coordinator service operating 24 hours a day, seven days a week. This role acts as a central point of contact across agencies and helps facilitate communication, coordination and information sharing between services involved in urgent mental health care. In addition, twice-daily bed management and operational coordination meetings are undertaken involving Mental Health Services, Approved Mental Health Professionals (AMHPs) and Police representatives. These meetings provide a structured opportunity for real time information sharing, discussion of current risks and coordination of responses across agencies. This arrangement was introduced since the death of Mr Evans and has strengthened collaborative working between partner organisations. Closer operational links have also been established between Mental Health Services and Dyfed-Powys Police through the Clinical Coordinator function and out-of- hours arrangements. Police officers regularly seek advice and support from this function, including consultation regarding Mental Health Act Section 136 matters. These contacts, discussions and clinical considerations are documented within the clinical record where relevant to support continuity of care and risk management. Furthermore, the implementation of NHS 111 Press 2 for Mental Health provides a single point of access for service users, families and carers seeking urgent mental health advice and support. The service facilitates timely access to mental health professionals and enables navigation and signposting across the wider mental health system, improving opportunities for early intervention, access to support and information sharing. 3. Safety planning and formulation-based practice The Health Board has implemented a person-centred safety planning approach across services, initially within inpatient settings and now extending into community services. The approach supports collaborative assessment and management of risk through active engagement with service users and their support networks. 4. Workforce development through WARRN The Health Board continues to deliver Wales Applied Risk Research Network (WARRN) training across mental health services. WARRN promotes a formulation-based approach to assessment and specifically emphasises: • gathering information from multiple sources • • seeking information from family members, carers and partner agencies where reviewing clinical records and historical information appropriate • avoiding reliance solely on an individual's account • multidisciplinary decision-making • documenting information sources and information sharing activities • ensuring risk assessment is linked to risk management and safety planning. The training explicitly promotes professional curiosity, collaborative working and shared responsibility for risk assessment and management. Immediate actions taken following the Coroner’s Inquest Following the Coroner’s Inquest, additional immediate actions have been undertaken. 1. Reinforcement of expectations regarding historical information review A formal professional practice reminder has been issued to all relevant mental health practitioners, medical staff and psychiatrists requiring them to review electronic patient records (Care Partner) prior to undertaking assessments. The instruction reminds staff that they must actively consider: • previous service involvement • documented risks • historical clinical information • relevant safeguarding and clinical concerns. The communication emphasises that failure to review available historical information may result in incomplete assessment and increased clinical risk. 2. Team discussions and practice reinforcement The requirements regarding review of historical information and consideration of collateral information have been discussed within operational team meetings across Adult Mental Health Services to reinforce expectations and support consistent practice. 3. Review of partnership information-sharing arrangements Work is underway with police colleagues to strengthen understanding and use of existing police handover processes within Pembrokeshire, ensuring important information is available to clinicians undertaking assessments when police have had recent involvement with an individual. 4. Strengthening the duty practitioner role The Health Board has commenced work to strengthen expectations regarding the role of duty practitioners undertaking urgent assessments, including clarification that assessment responsibility extends beyond analysing information presented and includes seeking additional collateral information where necessary to ensure a robust assessment. Further actions planned The Health Board recognises that the Coroner's concern extends beyond policy and procedure and relates fundamentally to professional culture, clinical practice and the approach taken to risk assessment. Independently of, and prior to, the Prevention of Future Deaths Report, the Health Board had already been actively engaged in a national programme of work aligned to the Open Access Mental Health Support Model, focused on strengthening approaches to risk, safety and system-wide responsibility for managing risk. This work reflects emerging national policy and best practice and was established before the conclusion of the inquest. A central aim of this programme is to support a shift from traditional models in which responsibility for risk management can be perceived to rest primarily with an individual practitioner, towards a culture of shared safety, professional curiosity, collaborative assessment and collective responsibility across services, agencies, communities and individuals. The Health Board considers that this direction of travel closely aligns with the issues highlighted by the Coroner and provides a strong framework through which these concerns can continue to be addressed. The Health Board is represented on the programme steering group and will be actively participating in four national workstreams that are currently being established: 1. Shifting the Risk Paradigm and Building a Just Culture 2. Person-Centred Safety and Shared Decision Making 3. Strengths-Based Crisis Response and Suicide Prevention 4. Community and System Leadership for Safety Implementation of learning and guidance arising from this programme will continue throughout 2026 and 2027 and will be reflected within local policies, workforce development programmes and clinical governance arrangements. Conclusion Hywel Dda University Health Board fully accepts the importance of the concerns identified by the Coroner and agrees that risk assessment should be informed by a comprehensive understanding of all relevant information available at the time of assessment. We believe the actions already implemented, the immediate actions undertaken following receipt of this report, and our ongoing participation in national safety and risk improvement work collectively address the issues identified and support the cultural shift towards collaborative, information-seeking, formulation-based assessment practice described by the Coroner. The Health Board remains committed to continuous learning and improvement to reduce the risk of future deaths and improve the safety of those accessing mental health services. Yours sincerely, Chief Executive Officer
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