Siwan Llio SMITH · Prevention of Future Deaths report

On 4/12/2020 an investigation was opened into the death of

Siwan Llio SMITH

The investigation concluded at the end of the inquest on: 9/9/2021

The conclusion of the inquest was recorded as:

Suicide

The medical cause of death was:

1a) Suspension by ligature

Siwan Smith had a long-standing history of anxiety and depression which was exacerbated during the Covid 19 pandemic. Siwan’s mental health deteriorated and she started to have suicidal thoughts. Siwan did not have ongoing support from either primary or secondary mental health services. On 23rd November 2020 Siwan became overwhelmed by her anxieties and took her own life by hanging at her home address.

1. Response to Mental Health Concerns by Reception Staff

During the course of the inquest, Mr Martin Smith, Siwan’s husband, raised concerns that on 18th November 2020, Siwan telephoned the Medical Centre to obtain an urgent appointment with a doctor. She was informed by the receptionist that the earliest appointment was on 30th November 2020.

The Medical Centre provided me with a report which indicated that when Siwan asked about whether there were any emergency appointments for mental health problems she was advised that these are not routinely offered unless a patient is having “bad thoughts”. Your report states that an emergency appointment was not requested and at no point was it suggested the call was a mental health emergency.

The Medical Centre provided me with a recording of the telephone exchange between Siwan and the receptionist. I found during the inquest that Siwan asked repeatedly if she could have an earlier appointment and was clearly upset that she could not. She was not asked if she was having bad thoughts or whether she required urgent mental health support. It was clear towards the end of the conversation that Siwan was distressed.

I also received in evidence a letter dated 8 March 2021 written By ████████, the Practice Manager to Mr Smith, in which she implies that the receptionists are not clinically trained to make assessments. I accept this, however in the circumstances I determined that Siwan should have received a call back from someone who was clinically trained to ascertain whether she required an urgent mental health assessment.

In the circumstances I did not find that a different course of action would have prevented Siwan’s death or would have altered the outcome. However I am concerned that lives could be put at risk in the future if there continues to be a lack of awareness of when a patient may require a clinical assessment in relation to their mental health.