Andrew Selwyn Roberts · Prevention of Future Deaths report

On the 28th of December 2011 I commenced an investigation into the death of Andrew Selwyn Roberts (DOB 16.5.1979, DOD 25.12.2011). The investigation concluded at the end of the inquest on the 17th of August 2015 when the jury returned a majority narrative conclusion in respect of the death in the following terms :-

It is more likely than not that Andrew Selwyn Roberts intended to suspend himself and it is more likely than not that he intended to kill himself but we cannot be sure of his intention.

The Medical Cause of Death was recorded as 1(a) Asphyxia by Hanging

The Circumstances of the death are that the Deceased was arrested by North Wales Police on the 24th of December 2011 in relation to an offence of threatening behaviour contrary to section 4 of the Public Order Act. He had been tazered in the course of his arrest and it was also known that he had taken an overdose and he was therefore taken from custody at St Asaph to the Emergency Department at Glan Clwyd Hospital.

At hospital he was assessed and it was deemed he was fit to be returned to custody. The custody nurse then telephoned the emergency department to request a transfer of care form which was completed by a nurse within the department and faxed back to her. This form inaccurately reported that the Deceased had been seen “assessed by a psychiatric liaison who doesn’t feel he has genuine mental health issues..”

He had in fact not been seen by anyone from the Psychiatric Liaison Team

1. That the Transfer of Care Form was not completed by the Doctor who had carried out the examination of the patient and the information contained therein was subsequently found to be inaccurate.

2. That the Transfer of Care Form was not completed at the time of examination and provided to the Police Officers escorting the detained person to hospital so that it could be returned with them to custody and made immediately available to the custody nurse.