Christopher Glyn Jones · Prevention of Future Deaths report

On the 16th of June 2015 I commenced an investigation into the death of Christopher Glyn Jones (DOB 6.7.88, DOD 11.6.15). The investigation concluded at the end of the inquest on the 2nd of September 2016 and I recorded a narrative conclusion in the following terms :-

“Christopher Glyn Jones was a twenty seven year old man who was suffering from a mental illness for which he was receiving care and treatment from the Betsi Cadwaldr University Health Board.

Although the individual care provided to him by members of staff reflected their desire to act in his best interests, his overall treatment was unsatisfactory due to delays in the formulation of treatment plans and risk assessments and failures in the provision of intended treatments and inadequate escalation of concerns at a time of significant decline in his mental health, although it cannot be said, even on the balance of probabilities, that this resulted in his death which was due to a deliberate act of self harm”

The Circumstances of the death are that the deceased died as a result of placing himself into collision with a train whilst under the care of the Community Mental Health Team

1. Evidence at the inquest indicated that the deceased was discharged from inpatient treatment on the 6th of January 2015 but his Care Treatment Plan was not completed until the end of April 2015 and that this would then only require review within a period of twelve months from that date, as a result it could have been the case that a patient who had recently been sectioned and treated as an inpatient may not then be seen by a consultant psychiatrist for a period in the region of sixteen months.

2. Furthermore evidence indicated that although additional resources were currently being made available and deployed for Mental Health within BCUHB, there was also an increasing demand on the service and as a result there may still be deficiencies of service, for example in providing acceptable levels of cover for staff at times of sickness/holidays etc.