A young artist with serious mental health issues was not properly assessed by health staff before he slipped security at a mental health ward and walked in front of a train, an inquest has heard. Robert Jones died after he was struck by a passenger train near Newport on September 28, 2019, less than a day after he had been admitted to hospital for mental health issues.
The day before he died Mr Jones had been admitted to St Cadoc’s Hospital in Caerleon after police found him “confused and covered in mud” on the A465 near Abergavenny, miles from his home in west Wales. However despite referring to suicide to police and after twice attempting to leave the hospital on Friday, September 27, he was placed on the lowest level of observation by health staff.
The following morning he slipped security by escaping via the ward’s communal garden before walking into the path of an incoming train. He was killed instantly.
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Senior coroner Caroline Saunders said Mr Jones, who was 25 when he died, was a “loving and gifted young man with a clear artistic talent” and “a loving son”. She said he had a history of mental health problems which could “prove overwhelming” at times.
On the night police found Mr Jones walking along the A465 they asked him whether he had any thoughts of self-harm or suicide, and he responded by talking about a bridge in Haverfordwest. Police detained Mr Jones under the Mental Health Act and brought him to St Cadoc’s in Caerleon. Ms Saunders said this was the “last and only time” anyone directly asked him about thoughts of suicide or self-harm.
She said Mr Jones, from Clynderwen, Pembrokeshire, had spoken about “hearing voices” in an initial assessment carried out by Eleanor Sparshott, deputy ward manager at the Bellevue ward at St Cadoc’s Hospital at the time, but that despite police having given information about him discussing a bridge he was not asked about suicidal thoughts during the assessment. The coroner said this should have been done and that failing to do so was an “omission” in Mr Jones’ care.
Ms Saunders said that although a Mental Health Act assessment carried out by two doctors and a mental health professional at around 4pm that day had discussed Mr Jones’ mood and voices in his head the clinical team were “unable to confirm” Mr Jones’ varying accounts about the voices and his thoughts of self-harm. She added that their findings were “not fully documented.”
Shortly after that assessment Mr Jones asked for some “fresh air” and was allowed outside of the hospital building where he tried to open a nearby van and, when asked by staff to stop, began walking down the driveway of the hospital. Staff from the hospital went to retrieve Mr Jones in a nearby laneway and after succeeding in bringing him into a car he later got out of the car via a window before once again being brought in and returned to the section 136 suite of the hospital.
Ms Saunders said evidence given by a mental health professional and team manager at Monmouthshire County Council’s social work team showed Mr Jones had come across “confused and confabulating” during the Mental Health Act assessment.
Ms Saunders said a further assessment should have explored Mr Jones’ risk of leaving the ward, given his attempts to leave that day, and that it was “not possible” to determine his level of risk as concerns had not been properly relayed to staff responsible for making decisions about his care. “This was a failure,” Ms Saunders said, adding that “no obvious consideration was given to Robert’s changeable and unpredictable behaviour”.
As painful as these proceedings are for those who have lost a loved one the lessons that can be learned from inquests can go a long way to saving others’ lives.
The press has a legal right to attend inquests and has a responsibility to report on them as part of their duty to uphold the principle of open justice.
It’s a journalist’s duty to make sure the public understands the reasons why someone has died and to make sure their deaths are not kept secret. An inquest report can also clear up any rumours or suspicion surrounding a person’s death.
But, most importantly of all, an inquest report can draw attention to circumstances which may stop further deaths from happening.
Should journalists shy away from attending inquests then an entire arm of the judicial system is not held to account.
Inquests can often prompt a wider discussion on serious issues, the most recent of these being mental health and suicide.
Editors actively ask and encourage reporters to speak to the family and friends of a person who is the subject of an inquest. Their contributions help us create a clearer picture of the person who died and also provides the opportunity to pay tribute to their loved one.
Often families do not wish to speak to the press and of course that decision has to be respected. However, as has been seen by many powerful media campaigns, the input of a person’s family and friends can make all the difference in helping to save others.
Without the attendance of the press at inquests questions will remain unanswered and lives will be lost.
Ms Saunders also referred to the decision to put Mr Jones on level one observation, which meant he was checked every 30 minutes on the night of his stay in the Adferiad unit. She said it had been “premature” to do this and that level two observation, under which patients are checked every 15 minutes, “should have been applied”. She said claims by staff that Mr Jones was “calm” during routine observational checks were not based on any assessment carried out by staff despite the fact the ward was not busy that night.
Mr Jones was awake from around 4.30am on the morning he died, making calls to his mother and attempting to charge his phone at the hospital. He was seen at 7.30am during a ward check but could not be located at 8am. Police were alerted but it was later confirmed that Mr Jones had been killed by a passenger train travelling from Cardiff to Crewe at around 8.05am on Saturday, September 28, 2019. “If Robert had been on 15-minute observations, his departure from the ward could have been prevented,” the coroner said.
A medical cause of death was recorded as multiple injuries. Delivering a narrative conclusion Ms Saunders said Mr Jones had “suffered from significant mental health problems” and that he “should have been placed on level two observations” given his references to suicide, self-harm, and attempts to leave the ward. She said: “His death was suicide which could have been prevented if he had been placed on the appropriate observation regime.”
However Ms Saunders added that “whilst mistakes were made” and elements of Mr Jones’ care had not been adequately carried out they did not amount to neglect on the part of the Aneurin Bevan University Health Board and there had been no absence of policy that would have put Mr Jones at risk. Noting his family’s concerns about the level of security at the ward, where there had been previous issues with patients absconding via the garden area, Ms Saunders acknowledged that improvements had since been made to the garden including improved lighting, alarm systems, and CCTV. She said resourcing issues were “manifold” across the health board and that it was not her role to determine which issues were prioritised and concluded that she would not be filing a prevention of future death report.
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