A CORONER is seeking assurance that people in need of mental health treatment cannot fall through a gap in systems.

Barrister Daniel Rogers, representing the Betsi Cadwaladr University Health Board, told an inquest that measures were now in place to prevent that from happening but John Gittins, senior coroner for North Wales East and Central, said he would be issuing a Prevention of Future Deaths report because he felt there was still a risk.

“And they are the most vulnerable people,” he said.

They were speaking at the end of an inquest into the death of 45-year-old chartered accountant Andrew John Shambrook, who was found hanged in the garden of his home in Ffrith, near Wrexham, on March 27, 2022.

Mr Shambrook, whose wife Shelley, described him as “a very intelligent man and a really engaging person”, said he first became depressed early in 2021, worrying about his financial situation.

His condition deteriorated, and in April was sectioned under the Mental Health Act. After a month in the Ablett unit at Glan Clwyd Hospital, he was discharged under the care of the service’s home treatment team.

In November he was sectioned again, this time at the Heddfan unit in Wrexham, and discharged on December 29.

Consultant psychiatrist Dr Sanjeevkumar Nirvani referred him to the home treatment team, but the inquest was told that the team felt he did not meet the criteria and was not considered a risk to himself or others.

“I didn’t feel that there was any need for him to be in hospital at that time,” he said.

Mr Shambrook’s care co-ordinator under Flintshire County Council, Ken Jones, said he spoke to him on March 15 and although he was “low” he gave no indication of intent to self-harm.

Mr Shambrook was prescribed anti-depressants and monthly injections of antipsychotic medication.

Mrs Shambrook said that by the end of March, he was “absolutely tortured” and she pleaded for help.

“He was so depressed he didn’t feel worthy of anyone’s help,” she said.

On Friday, March 25, Mrs Shambrook took their two children away for the weekend and called the police when he did not answer her phone calls. Officers found him in the garden.

Members of Mr Shambrook’s family said that one of their concerns was the lack of information they were given and the coroner said that poor communication was a “regular theme” of his.

Recording a conclusion of suicide, Mr Gittins said there was no place in the system and no recognised pathway for those who did not meet the home treatment team’s criteria.

Despite Mr Rogers’s comment that such people were not left unsupported, the coroner added: “In the absence of a recognised protocol I do feel there is a risk that people can fall through the gap and they are the most vulnerable people.”