Paul Anthony Roberts · Prevention of Future Deaths report

On the 29th of August 2023 I commenced an investigation into the death of Paul Anthony Roberts (DOB 16.4.64 DOD 15.8.23). The investigation concluded at the end of the inquest on the 17th of July 2024. The cause of death was recorded as being due to (1a) Knife Injury to heart and the conclusion of the inquest was one of misadventure as although this was a self-inflicted injury there was evidence to support the view that it was not by way of an intention to end his life.

In February 2023 the deceased took an overdose and inflicted multiple stab wounds to himself. He had a referral to mental health services and an initial assessment by the home treatment team who then passed his care to the local primary mental health support service (LPMHSS). At this time his case was effectively “lost in the system” and he received no further mental health support.
On the 14th of August 2023 he attended the emergency department (ED) at Glan Clwyd Hospital due to concerns around a further deterioration in his mental health. Although he was triaged, no referral for a psychiatric assessment was made for a number of hours and by the time that this error was rectified and psychiatric liaison attended the ED, Mr Roberts had left the department.
The following day he harmed himself by way of multiple wounds and died as a result of the same.

An investigation by the Health Board had identified that there were failings in relation to the care afforded to Mr Roberts both following the February mental health referral and at ED on the 14th of August, however the evidence at inquest indicated that the persons with responsibility for these issues had not been spoken to, nor played a part in the investigation process (respectively being the team manager of LPMHSS and the nurse in charge of ED).

Furthermore an action plan provided by the health board advised that by the end of May 2024 a leaflet would be available and would be given to patients attending ED with mental health issues and would be provided to them at the time of triage to provide advice, support and an indication of likely waiting times there are any psychiatric assessment took place.

My concerns are therefore as follows :

1. There do not appear to be any consequences for staff members whose actions or omissions result in a failure to adhere to the policies and procedures which the health board impose for the safe care and treatment of patients and in my opinion this lack of accountability perpetuates future risk to patients.
2. The failure to act in a timely manner when learning and actions have been identified (especially when the timetable has been set by the organisation itself) is incomprehensible and as a result there is a failure to mitigate the risk to patients.