“Mrs Edwards’ discharge from hospital following overdose on 23" August to see GP was…”
Dated 18 Dec 2018, from the coroner for South Wales Central. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Report put online after its 56 daysOrganisations 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.
judiciary.uk put this report online on 17 May 2019, after the 56 days for replies had ended (12 Feb 2019). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated18 Dec 2018
- Deadline12 Feb 2019
- Published on judiciary.uk17 May 2019
- Today21 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Cardiff and Vale University Health Board | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| West Quay Surgery | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— (1) Mrs Edwards’ discharge from hospital following overdose on 23" August to see GP was surprising. It was expected in these circumstances that Mrs Edwards would have been transferred to Llandough Hospital for a psychiatric liaison assessment. Instead, responsibility for any further assessment and treatment of Mrs Edwards was passed entirely to Mrs Edwards and her family. A less capable family/individual may not have pursued help and fallen through the cracks. Furthermore, had Mrs Edwards been hospitalised, her treatment may have been different. (2) The consultation at the UHW on 23" August was poor. The history-taking was inadequate, as it did not reveal the true extent of Mrs Edwards’ risk in terms of previous suicide attempts and deep-seated mental health problems. Furthermore, inaccurate information was communicated to liaison psychiatry: they were told that Mrs Edwards had taken 2 tablets, when she had taken 20. (3) The GP practice may not have performed suitably frequent medication reviews with Mrs Edwards. Many boxes of different tablets were found at the family home, many on repeat prescription, posing an overdose risk. ‘ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action. You may wish to consider the following point {a) The identification of patients who require immediate psychiatric assessment and review by specialist teams; (b) The care and attention to detail taken by doctors and other healthcare professionals when noting histories and information from mental health patients; and {c) The frequency of medication reviews with mental health patients.
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, 2018-0395
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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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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