Mr Twm Bryn · Prevention of Future Deaths report

On the 12th October 2021, I commenced an investigation into the death of Mr Twm Bryn, aged 21. The investigation concluded at the end of the inquest on the 15th February 2023.

Mr Twm Bryn died on the 4th October 2021 in a shipping container located near his home address having suspended himself by the neck with a ligature.

Mr Twm Bryn had experienced mental health difficulties, including anxiety and low mood since the age of 17. Mr Bryn was referred to Gwynedd Mental Health services after a telephone consultation with his GP on the 26th July 2021. Due to the presence of low mood and anxiety, the referring Dr requested a routine assessment and possibly counselling.

Mr Bryn lived with family, had good friends and a job that he liked. The referral outlined low mood for a “few” years with a deterioration in the last “few” months which included feelings of panic, tiredness, poor sleep and appetite with no reported use of illicit substances or excessive alcohol consumption. The referral indicated that Twm Bryn described to the GP feelings “hitting him like a wall” when upset and angry, and at times, thoughts of wanting to harm himself and occasional suicidal thoughts.

An appointment with the Local Primary Mental Health Support Service (“LPMHSS”) was arranged and took place, via telephone assessment, on the 7th September 2021, 40 days after Mr Bryn was seen by the GP (not within the 28 day target set by the Mental Health Measure). The assessment indicated the presence of long-term low mood accompanied by anxiety, poor sleep and appetite. He was assessed as a mild risk of suicide, and no risk of harm to others with no legal/forensic risk. Mr Bryn was not at risk of abuse in his personal relationships nor at home and no safeguarding concerns were identified.

The primary care assessment was discussed at an Allocation meeting on the 13th September 2021 where a decision was made to offer counselling with the Local Primary Mental Health Support Service. There was a waiting list of several months for the said counselling and save for services to which he would need to self-refer, no interim contact, monitoring or support was discussed or offered to Mr Bryn.

Mr Bryn died before counselling was made available to him.

(1) Continued staffing pressures within Primary Mental Health Services resulting in assessment delays and waiting lists for support e.g the waiting list for LPMHSS counselling remains at 4 – 6 months. There was no evidence that the waiting list would improve moving forward.

(2) Whilst awaiting counselling, the only interim support available to patients that are assessed as mild or low risk, are services that come with a requirement to self-refer, despite lack of motivation being a common symptom. The LPMHSS does not have a standardised process for referring low risk patients for interim support and no interim contact or monitoring is offered or arranged (unless patients have self-referred to an organisation providing such services).