“Isaac Arlan Ingle-Gillis presented to his GP on 20/12/2024 having made preparatory…”
Dated 22 Jul 2025, from the coroner for Gwent. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 16 Sep 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated22 Jul 2025
- Deadline16 Sep 2025
- Published on judiciary.uk28 Jul 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Aneurin Bevan University Health Board | Response publishedPublished on judiciary.uk in July 2025. |
The coroner’s concerns
Isaac Arlan Ingle-Gillis presented to his GP on 20/12/2024 having made preparatory attempts to obtain to end his life and had attempted to stab himself through the heart. The GP referred Isaac to the Crisis Resolution and Home Treatment Team (CRHTT), who duly assessed Isaac later that day. The assessment included information obtained from a telephone conversation with the GP prior to the assessment. Isaac was discharged following the assessment without follow up. Thereafter Isaac engaged with his GP but took his own life on 9/2/2025, in the circumstances described in Box 4. During the inquest I heard evidence that the CRHTT do not have access to the GP records. I could not determine on balance of probabilities that access to additional information recorded by the GP in their consultation with Isaac on 9/2/2025 would have changed the assessment made by the CRHTT on this occasion. However, I am concerned that in future this information (or lack of it) may be vital.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0373
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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