Coroner finds that Andrew Davies’ death, 21 days after his discharge from a mental health ward at Neath Port Talbot Hospital, was caused by failures in the discharge process and lack of sufficient follow up care in the community

Andrew, a much loved son, brother and partner, was unfortunately found at home on 9 September 2019, having died by hanging after intending to take his own life. 

Andrew had a diagnosis of schizo-affective disorder and had struggled with his mental health for many years, having previously been diagnosed with paranoid schizophrenia and bipolar disorder. He had a history of self-harm, attempted suicide and poor medication compliance and had previously had a number of inpatient admissions to psychiatric hospitals. Shortly prior to his death, on 18 July 2019, Andrew has been admitted as an inpatient under section 2 of the Mental Health Act 1983, following a significant decline in his mental health. 21 days after his discharge, on 9 September 2019, Andrew was unfortunately found at home by his partner and was pronounced dead.  

Following a four-day inquest – where detailed evidence was heard from various witnesses from both Swansea Bay University Health Board and Neath Port Talbot Council, including an independent expert Consultant Forensic Psychiatrist – the Coroner concluded that the lack of an appropriate discharge process and lack of sufficient follow up care in the community more than minimally contributed to Andrew’s death. 

On 18 July 2019, Andrew was admitted to Ward F at Neath Port Talbot Hospital, following a period of increased paranoia and agitation. A referral to the Community Mental Health Team (‘CMHT’) was made on or around 26 July 2019 by Andrew’s Consultant Psychiatrist. At the beginning of August 2019, Andrew attempted to appeal his section at a Mental Health Tribunal but was unsuccessful. The Coroner heard evidence that if Andrew had been discharged at that time, CMHT support would have been urgently put into place. Following the Tribunal, the CMHT reverted back to treating Andrew’s case as routine and no further steps were taken prior to his later discharge from hospital. 

At the time of Andrew’s eventual discharge on 19 August 2019 – when he had limited insight into his condition and was still having paranoid symptoms – his Consultant Psychiatrist was under the mistaken impression that Andrew was being care coordinated by the CMHT, despite no CMHT assessment having been undertaken and no care coordinator having been allocated to his case. The Coroner found that whilst the plan had been to discharge Andrew with lots of support, the discharge planning process was flawed as such support was not forthcoming until it was too late, and that Andrew should not have been discharged without such support in place. The Coroner also found that there had been a reliance on Andrew’s family to flag concerns and that the support provided to him had been reactive, not proactive, for an 18-day period following Andrew’s discharge. There had been no checks and no monitoring of Andrew’s compliance with his medication and the standard of care provided was not adequate. His discharge had been dependant on community follow-up, which had not occurred. 

The family were represented by Rachel Woodward instructed by Ela Lloyd-Evans of Harding Evans Solicitors

The other Interested Persons were Swansea Bay University Health Board and Neath Port Talbot Council. 

The Coroner was HM Assistant Coroner for Swansea and Neath Port Talbot, Aled Gruffydd. 

For further enquiries about Rachel, please contact Senior Practice Manager Melvin Warner