DANIEL WILLIAMS · Prevention of Future Deaths report

On 21st June 2013 I commenced an investigation into the death of DANIEL WILLIAMS, AGE 24. The investigation concluded at the end of the inquest on 2ND JANUARY 2014. I concluded that the cause of death was 1a HANGING and returned a NARRATIVE CONCLUSION as follows:

In May 2013 Daniel Williams was admitted to St Catherine’s Hospital following an episode of deliberate self harm by way of insulin overdose. This was on a background of psychiatric problems which developed following a diagnosis of diabetes which had profoundly effected him.

During the course of his admission superficial enquiries by staff and unreliable record keeping compromised the quality and completeness of the clinical information which in turn compromised the effectiveness of the risk assessments. Poor communication exacerbated matters. All these factors served to further increase Mr Williams’ significant risk of self harm.

On 15 June 2013 Daniel Williams died from hanging following self application of a ligature in his room at St Catherine’s Hospital.

Daniel Williams had been diagnosed as suffering from Diabetes at the age of 19. This profoundly affected his mental wellbeing and also had physical implications too. As a consequence he engaged with the psychiatric services and his final admission to hospital was on the 23rd May 2013 following an overdose of insulin. Mr Williams suffered from suicidal thoughts for much of that admission and appeared to be considering alternative methods for ending his life. There were a number of risk assessments and one to one meetings, many of which appeared not to explore in any depth his suicidal thoughts and intent. On the 15th June 2013 Mr Williams hanged himself with a bedsheet by knotting one end and securing it in the door jamb to the en suite bathroom and tying the other end tightly around his neck.

(1) Quality of staff training, particularly with regard to record keeping and communication.
(2) The emphasis on taking a holistic approach to care and whether there is an imbalance between adopting such an approach and patient safety.
(3) The absence of clear guidance for checking patients and their rooms for potential self harm items both in the rooms themselves and for items brought into the hospital.
(4) The absence of a single reference sheet in the notes summarising key issues, risk factors, significant incidents and concerns readily accessible to all involved in patient care.