A 61-year-old man who died in his flat in Flintshire was "let down badly by the health board", an inquest has heard. 

Paul Anthony Roberts died at his flat at Castle Heights in Flint on August 15, 2023. 

At County Hall in Ruthin on Wednesday (July 17), an inquest was held into the 61-year-old's death. 

The family of Mr Roberts said they had "very serious concerns" over the care he received prior to his death in August last year. 

It heard that Mr Roberts had a history of mental health issues, suffering with depression and anxiety from an early age. 

The former decorator from St Asaph made an attempt to take his own life on February 6, 2023.

After being admitted to the emergency department at Glan Clwyd, Mr Roberts was discharged two days later, showing "remorse" after what had happened, and was seeking help. 

On February 9, Mr Roberts was visited by the home treatment team from Betsi Cadwaladr, who undertook a home assessment and referred him to the local primary mental health support as well as the substance misuse team. 

However, the inquest heard that Mr Roberts' referral was "lost in the system" and therefore wasn't processed, meaning he didn't get seen by a mental health nurse, nor get the support he was seeking. 

On August 14, 2023, a day before his death, Mr Roberts contacted his son Carl at around 5.15pm asking to go to hospital as he was having suicidal thoughts. 

Mr Roberts was picked up by his son, who took him to the emergency department at Glan Clwyd, arriving at around 5.30pm.

Whilst in A+E, Mr Roberts was assessed and described as "emotional" throughout, discussing how he was contemplating ending his life and his mental health background.

He was then referred to the psychiatric team at around 10pm, as a category two patient, with "no concerns" over Mr Roberts waiting to be seen. 

Having waited in A+E for around five or six hours, Mr Roberts asked to go home as he didn't want to wait in the department any longer. 

Mr Roberts and his son then returned to his son's address, where they stayed the night before being taken back to his home address the following morning. 

Carl Roberts described his dad as being "fine" the morning of August 15. 

That morning, Mr Roberts' sister Moira Lloyd visited him at 10.30am for around half an hour, to check on him. 

Mrs Lloyd said that Mr Roberts had told her that he was due to go to a mental health appointment at the end of July, but didn't attend. 

She then left, where she rang the nurse about her brother's appointment, before returning shortly after 12pm.

When she arrived, she shouted his name as usual, but Mr Roberts replied "don't come in". 

Mrs Lloyd said "she knew" what was going on and immediately called an ambulance. After entering Mr Roberts' room, Mrs Lloyd said that he had sustained injuries from a knife. 

Emergency services arrived, but despite the best efforts of both police and paramedics, Mr Roberts died at the scene. 

John Gittins, senior coroner for North Wales East and Central said that Mr Roberts showed indications of wanting help and therefore recorded a conclusion of misadventure. The cause of death was a knife injury to the heart.

He added that the care provided to Mr Roberts "wasn't good enough" and that the 61-year-old was "let down badly by the health board". 

Mr Gittins said he was to issue two prevention of future death reports to Betsi Cadwaladr Health Board following the "unacceptable" nature of the case. 

One was based on accountability following the issues that arose prior to Mr Roberts' death. Secondly, regarding what is being done to prevent similar situations.

In a report to the coroner, the health board said they would introduce leaflets to give to patients suffering with mental health issues in A+E, in a bid to signpost them to the correct service. They were meant to be brought in by May of this year, but have yet to be introduced, much to the frustration of Mr Gittins. 

Anyone struggling with their mental health can call Samaritans for free on 116 123, email them at jo@samaritans.org, or visit samaritans.org