Robert Maxwell SMITH · Prevention of Future Deaths report

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

These were recorded as follows

Robert Maxwell Smith died on 26th October 2023 at ████████, Cardiff . Mr Smith died by hanging ████████. 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

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.