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Investigation and inquest
On 18th February 2014 I commenced an investigation into the death of Mihangel ap Dafydd. The investigation concluded at the end of the inquest on 29 April 2016. The conclusion reached by the jury was a narrative one namely that:
On 16th February 2014 Mihangel ap Dafydd hanged himself on Morlais Ward Glangwili Hospital. He was properly assessed under the Mental Health Act upon his admission to hospital. His level of observation was appropriate in the circumstances. The procedure for removing items of property which could be used for the purposes of self-harm was undertaken incorrectly. The hospital unit had not been correctly adapted to prevent windows being used as a ligature point. These failings did contribute to his death.
Circumstances of the death
(1) On 14th February 2014 Mr ap Dafydd was exhibiting signs of mental illness and was assessed as being at risk of self-harm.
(2) He was detained under the Mental Health Act and placed under 15 minute observations on Morlais Ward Glangwili Hospital.
(3) He was checked during the early hours of 16th February and was found hanging from a window having used a strap from his bag.
Coroner’s concerns
The windows in service user areas at Morlais Ward are not ligature free and whilst it is intended to make them so following the death of Mr ap Dafydd this work has not yet been undertaken.
Information checked against the published report and official responses