Christopher John Llewellyn Roberts · Prevention of Future Deaths report

On 8th January 2016 I commenced an investigation into the death of Christopher John Llewellyn Roberts. The investigation concluded at the end of the inquest on 4 October 2017.

The medical cause of death is
1a opiate toxicity

The conclusion of the inquest as to how Mr Roberts came to his death is a narrative one and is as follows:-

The deceased died of overdose of prescription medication. The intent to take his own life could not be proven to the required standard.

The deceased was Christopher Roberts and he was pronounced dead on the 19th of October 2015 at his home address of 57 St Nicholas Square, Swansea Marina, Swansea. The cause of death was a deliberate overdose of his pain relieving opiate prescription medicine, MST Continus, with 498mcg/L of morphine being found in his blood by way of a toxicology report.

Christopher was receiving treatment for mental illness by the Community Mental Health Team (CMHT). Christopher was diagnosed as having a depression and anxiety coupled with borderline personality traits. Christopher's care plan was written in February 2014 and a review was planned for February 2015. The evidence of the Community Psychiatric Nurse (CPN) was that the review had been carried out with no changes to the care plan, however this was never recorded. Shortly before the care plan was due to be reviewed, Christopher made an attempt on his life by way of overdose. There was no evidence or decision making trail to confirm whether this issue was considered when deciding if the care plan should remain the same.
The care plan stipulated that the deceased was responsible for his medication and that this would be administered by way of a dossette (or nomad tray) and would be prepped on a weekly basis. The evidence was that the deceased’s medication regime was chaotic with tablets being taken in the wrong order or not being taken at all. This was known to CMHT by way of reports from the deceased’s support worker, and from admissions by the deceased himself.

1. The care plan review was not recorded which would not allow another person reviewing the file to ascertain that a care plan review had taken place and what the outcome of that review was. It was also the case that a lack of documentation would not demonstrate whether CMHT had considered the matter of the attempt on his own life by the deceased in the weeks leading up to that review, when considering whether to amend or retain the care plan in place at the time.
2. Nomad trays may be unsuitable in dispensing medication to some patients, which may deprive them of the benefits in taking that medication.