A PREVENTION of Future Deaths Report has been issued following the passing of a man from Flintshire "let down badly by the health board". 

Last month, the Leader reported on the inquest held into the death of 61-year-old Paul Anthony Roberts at his flat at Castle Heights, Flint. 

The inquest, held by John Gittins, senior coroner for North Wales East and Central, heard that following an attempt at his own life in March 2023, Mr Roberts had been referred to mental health services, but following a home assessment, his case was "lost in the system" meaning he received no further support. 

On August 14, 2023 he attended the emergency department (ED) at Glan Clwyd Hospital due to concerns around a further deterioration in his mental health.

Although he was triaged, no referral for a psychiatric assessment was made for a number of hours and by the time that this error was rectified and psychiatric liaison attended the ED, Mr Roberts had left the department.

The following day he harmed himself  and died as a result.

Mr Gittins said he was to issue a Prevention of Future Death Report following Mr Roberts' passing, which has now been published. 

In the report, Mr Gittins said that during his investigations, evidence revealed matters "giving rise to concern" and that there is a risk future deaths could occur unless action is taken. 

Mr Gittins said: "An investigation by the Health Board has identified that there were failings in relation to the care afforded to Mr Roberts both following the February mental health referral and at ED on the 14th of August, however the evidence at inquest indicated that the persons with responsibility for these issues had not been spoken to, nor played a part in the investigation process (respectively being the team manager of LPMHSS and the nurse in charge of ED).

"Furthermore an action plan provided by the health board advised that by the end of May 2024 a leaflet would be available and would be given to patients attending ED with mental health issues and would be provided to them at the time of triage to provide advice, support and an indication of likely waiting times before any psychiatric assessment took place.

"My concerns are therefore as follows:

"1. There do not appear to be any consequences for staff members whose actions or omissions result in a failure to adhere to the policies and procedures which the health board impose for the safe care and treatment of patients and in my opinion this lack of accountability perpetuates future risk to patients.

"2. The failure to act in a timely manner when learning and actions have been identified (especially when the timetable has been set by the organisation itself) is incomprehensible and as a result there is a failure to mitigate the risk to patients."

The Health Board now has 56 days to respond to the report, which is by September 12, 2024.

Following the inquest, Carol Shillabeer, Chief Executive at Betsi Cadwaladr University Health Board, said: “On behalf of the Health Board I am profoundly sorry and offer my deepest sympathies to Paul’s family for their loss.

“The care Paul received fell below the standards we and his family would expect, and we sincerely apologise for this.

“We take the coroner’s findings very seriously and we will continue to ensure we learn and address the concerns raised in their conclusion. We will fully respond to his concerns in due course.”