David Nigel Phillips · Prevention of Future Deaths report

On 4th January 2015 I commenced an investigation into the death of David Nigel Phillips aged 71. The investigation concluded at the end of the inquest on 8th September 2016. The conclusion of the inquest was an Open Conclusion and the medical cause of death was 1a Drowning.

The deceased was David Nigel Phillips and he died on the 4th January 2015 at the beach alongside Mumbles Pier Mumbles Swansea where he was found drowned lying on his back in a rock pool. David had a history of mental illness and had previously attempted to take his own life on a number of occasions. The day before he died he was found intoxicated at his wheel of his parked car in Rhosilli Gower. He was arrested and taken to Swansea Central Police Station. He was examined by a Senior Forensic Nurse (Mitie) who carried out a fitness for detention, interview and release assessment. David was assessed at low risk of self-harm.

David stated in interview that he had been attempting to take his own life. He had driven to Rhossilli and had consumed alcohol to desensitise himself before proceeding to end his life.

David expressed concerns that his prescription of diazepam had been reduced to a lower dose which he did not feel to be sufficient.

He was charged and bailed to appear at Swansea Magistrates Court at later date and then released to his partner (who he had disclosed in interview to be also suffering from depression and causing him concerns). David was a type 2 diabetic and had alcohol related issues.

The following morning David was found dead on the beach near Mumbles Pier. Cause of death was initially given as unascertained by the pathologist in her autopsy report but having heard and seen further evidence including photographic evidence this was changed to drowning.

However, It was not possible to establish exactly where when or how he came to enter the water. Although the circumstances pointed to deliberate self harm this could not be proven beyond all reasonable doubt. It was not possible to exclude a possible insulin related cause, accident or a deliberate act. No note of intention was found. The evidence does not fully or further disclose the means whereby the cause of death arose to the required standards and an open conclusion was recorded.

Although, suicide could not be established to the criminal standard of proof, the circumstances pointed to this as a strong possibility as to how David came to his death.

Many people who come into custody or police contact do so with physical or mental vulnerabilities or both. The safer detention and handling of persons in police custody guidance, strongly promotes and advises engaging the right healthcare professional at the right time and in the right place.

David Phillips was aged 71. Generally people over 65 years who self-harm should be assessed by mental health professionals experienced in the assessment of older people who self-harm. A mini- mental state examination tool was used.

My concerns are that:-

(1) An experienced mental health doctor or nurse should have been called to carry out the assessment rather than a nurse. The quality of the assessment is critical rather than a box ticking exercise.

(2) The Health Care Professional did not have access to detainee’s medical records to accurately identify reasons as to why and how medications are changed or as to when this may or may not have occurred.

An ability to review medication and if necessary prescribe medication would be helpful and access to medical records is critical. Access to electronic Individual Health Records to include mental health records