Trevor Anthony Evans · Prevention of Future Deaths report

On 28ᵗʰ February 2020 an investigation into the death of Trevor Anthony Evans, aged 54 years, was commenced by the then Senior Coroner, Mark Layton. The investigation concluded at the end of a five-day inquest, heard by me, between 13ᵗʰ April 2026 and 17ᵗʰ April 2026. During the inquest I heard evidence allowing me to make the following findings:

The medical cause of death was: Asphyxia by hanging

How, when and where: Trevor Anthony Evans died as a result of hanging himself on 27th February 2020 ████████ at his home address of 37 Whitehall Drive, Pembroke in circumstances where he was struggling with his mental health and in the absence of a thorough mental health risk assessment being undertaken.

Conclusion: Suicide

[Please explain the relevant circumstances of the individual’s death, ideally this should be in no more than 500 words]

During the inquest I heard evidence on events that occurred during the period 18ᵗʰ February 2020 through to the date of Trevor’s passing on 27ᵗʰ February 2020. The evidence focused specifically on Trevor’s contact with the police, ambulance service, mental health professionals and health care staff during that period.
Trevor was struggling with his mental health during this period and his conduct was such that his family, the police and the ambulance service all had concerns for his mental health which culminated in a GP making an emergency referral for a mental health assessment.
On 24ᵗʰ February 2020 Trevor was assessed by a Community Mental Health Nurse. After hearing evidence, I found that there was an over reliance on what Trevor told the nurse, a failure to review medical records and a lack of investigation or scrutiny into an abundance of background information that was available.
With hindsight had all of that information which was readily accessible been reviewed then a referral to the Mental Health Crisis Team would have been appropriate.
Trevor sadly took his own life on 27ᵗʰ February 2020.

In this case, I found that there was an over reliance on what Trevor told the nurse, a failure to review medical records and a lack of investigation or scrutiny into an abundance of background information that was available.

Notwithstanding the fact that I have been told that changes have been made by the Health Board to ensure that those undertaking assessments now look to obtain as much information as possible I also received evidence which indicates that assessors still harbour an attitude that it is the referrer job to provide all the relevant information and then those performing the risk assessment will simply assess the information.

For as long as that approach or culture continues I fear that mental health risk assessments in Pembrokeshire may be incomplete, perfunctory and inadequate. There needs to be a shift of onus to a more collaborative approach so that those undertaking the assessment explore what information is available to them and do not simply rely on the details provided by the referrer. It is essential that those undertaking the mental health assessments are aware of the need to obtain as much information as possible in order to complete a full and thorough assessment of the risk and that they are aware of how to and where to obtain the relevant information from.