“is as follows: I heard evidence during the inquest that in January 2021, March 2021, and…”

The coroner’s concerns

is as follows: I heard evidence during the inquest that in January 2021, March 2021, and December 2021 the Harrison family made three formal requests for a mental health act assessment under the MHA 83 in respect of their son in their capacity as Nearest Relatives (NR). On receipt of a NR request, the local social services authority (City and County of Swansea (‘CCoS’)) is under a legal duty pursuant to s.13(4) MHA 83 to make arrangements for an Approved Mental Health Practitioner (‘AMPH’) to consider the patient’s case as part of their consideration as to whether to make an application for admission to hospital. The Mental Health Act 1983 Code of Practice for Wales (‘MHACOP Wales’) states that in considering a patients case an AMPH must come to their own independent view based on social and medical evidence and that they should recognise the value in involving other people in the decision-making process where that person is able to offer a particular perspective on the patient’s circumstances and that they should consult wherever possible with other 3 people who have been involved in the patient’s care. In respect of the request in January 2021, I found that the AMPH did not collect sufficient collateral information before visiting and assessing in person and prior to the formal assessment under the MHA 83 on 9 February 2021. I also found that the assessment of 9 February 2021 was a formal assessment under the MHA 83 and that it did not comply with the MHA 83 as only one doctor and an AMPH attended to assess in person where the requirement is that two doctors must attend to assess the patient. This was not an emergency assessment. I found that in respect of the second NR request (when was in police custody in March 2021) there was a failure by the AMPH to act in accordance with the s.13(4) MHA 83 duty because it cannot be said that the AMPH adequately considered case as sufficient collateral information was not obtained and considered prior to the decision by the AMPH not to undertake a formal mental health act assessment on whilst he was in police custody as requested by the Harrison family in their capacity as the NR. I found that the response of the AMPH service to the third NR request from the Harrison’s on 19 December 2021 (which was to refuse to carry out a formal mental health act assessment) was not in accordance with s.13(4) MHA 83 as no collateral information was sought and what had been provided by the Harrison family was not afforded sufficient weight with reliance being placed solely on the records on the system which were out of date. I heard evidence during the inquest that a senior manager in the AMPH service maintained to the Swansea University Bay Health Board (‘SBUHB’) that the assessment of 9 February 2021 complied with the MHA 83 (when it did not) and did not at any stage make clear to the SBUHB that the AMPH service had not gathered sufficient collateral information, including that suggested by the Harrison family, prior to assessing . I am concerned that an inadequate understanding within the CCOS AMPH service of the duty to gather sufficient collateral information in the context of any assessment under the MHA 83 and / or inadequate systems being employed within CCOS in relation to this issue creates a risk that information may not be captured and / or may be lost in relation to mentally unwell individuals in the community where they may pose a risk to their own lives and / or the lives of others and that this creates a risk that other deaths will occur. The second MATTERS OF CONCERN is as follows: It is a mandatory requirement of the MHACOP Wales that a medical examination by a doctor of a patient in a formal assessment under the MHA 83 where they are considering admission to hospital must involve consideration by that doctor of all available relevant clinical information. I heard evidence in the inquest that doctors approved under s.12 MHA 83, and used by SBUHB to conduct assessments under the MHA 83, only have access to a patient’s medical records if they are employed by SBUHB. I heard that SBUHB rely heavily on s.12 doctors who are not directly employed by them and / or are locum doctors. I also heard that there is no system within SBUHB to ensure s.12 doctors are required to record the outcome of their assessment when there is a decision not to admit a patient to hospital. I heard evidence that there is no single digital record system / platform for Mental Health Services and associated access for practitioners across Wales. I am concerned that there is a system in place (or a lack of a system) in SBUHB and more widely across the NHS in Wales which is placing s.12 doctors at risk of acting contrary to the MHACOP Wales where they are unable to view a patient’s medical records prior to an assessment under the MHA 83. I am concerned that this creates a risk that assessments may be flawed and / or may not detect that a person requires admission to hospital in circumstances where that patient may pose a risk to their own life and / or to the lives of others and that this 4 creates a risk that other deaths will occur. In addition, if a s.12 doctor is unable to record their assessment in a patient’s medical records there is a risk that important information may not be documented which may be relevant to an understanding of the risk a patient may pose to themselves or others thus creating a risk that other deaths will occur. The third MATTER OF CONCERN is as follows: I heard evidence that Ward F of Neath and Port Talbot hospital is being used as the Single Point of Admission (‘SPOA’) for all adults requiring hospital admission in the locality for assessment of their mental illness. I heard that Ward F is a 21 bedded unit and that the move to using just Ward F as the SPOA (as opposed to three units which had been the practice) was brought in during the Covid-19 pandemic to manage the spread of the Covid 19 virus but that this change had been under consideration i

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, 2024-0224

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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