David Phillips
PFD Report
Historic (No Identified Response)
Ref: 2016-0334
No published response · Over 2 years old
Sent To
Response Status
Responses
0 of 3
56-Day Deadline
11 Nov 2016
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coronersconcerns
Many people who come into custody or police contact do s0 with physical or mental vulnerabilities or both. The safer detention and handling of persons in police custody guidance, strongly promotes and advises engaging the right healthcare professional at the right time in the right place_ David Phillips was aged 71. Generally people over 65 years who self-harm should be assessed by mental health professionals experienced in the assessment of older people who self-harm. A mini-mental state examination tool was used, My concerns are that:- (1) An experienced mental health doctor or nurse should have been called to carry out the assessment rather than a nurse. The quality of the assessment is critical rather than a box ticking exercise (2) The Health Care Professional did not have access t0 detainee's medical records to accurately identify reasons as t why and how medications are changed or as to when this may or may not have occurred: An ability to review medication and if necessary prescribe medication would be helpful and access to medical notes is critical_ Access to electronic Individual Heath Records to include mental health records and
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe organisations have the power to take such action:
Report Sections
Investigation and Inquest
On 4th January 2015 commenced an investigation into the death of David Nigel Phillips aged 71. The investigation concluded at the end of the inquest on 8th September 2016. conclusion of the inquest was an Open Conclusion and the medical cause of death was Ia Drowning:
Circumstances of the Death
The deceased was David Nigel Phillips and he died on the 4th January 2015 at the beach alongside Mumbles Pier Mumbles Swansea where he was found drowned lying on his back in a rock pool. David had a history of mental illness and had previously attempted to take his own life on a number of occasions. The before he died he was found intoxicated at the wheel of his parked car in Rhossilli Gower. He was arrested and taken to Swansea Central Police Station: He was examined by a Senior Forensic Nurse (Mitie) who carried out a fitness for detention; interview and release assessment; David was assessed at low risk of self-harm: The day
David stated in interview that he had been attempting to take his own life_ He had driven to Rhossili and had consumed alcohol to desensitise himself before proceeding to end his life. David expressed concerns that his prescription of diazepam had been reduced to a lower dose which he did not feel to be sufficient; He was charged and bailed to appear at Swansea Magistrates Court at later date and then released to his partner (who he had disclosed in interview to be also suffering from depression and causing him concerns) David was a type 2 diabetic and had alcohol related issues. The following morning David was found dead on the beach near Mumbles Pier. Cause of death was initially given as unascertained by the pathologist in her autopsy report but having heard and seen further evidence including photographic evidence this was changed to drowning: However, It was not possible to establish exactly where when or how he came t0 enter the water. Although the circumstances pointed to deliberate self harm this could not be proven beyond all reasonable doubt: It was not possible to exclude a possible insulin related cause, accident or a deliberate act: No note of intention was found, The evidence does not fully or further disclose the means whereby the cause of death arose to the required standards and an open conclusion was recorded: Although; suicide could not be established to the criminal standard of proof, the circumstances pointed to this as a strong possibility as to how David came to his death:
David stated in interview that he had been attempting to take his own life_ He had driven to Rhossili and had consumed alcohol to desensitise himself before proceeding to end his life. David expressed concerns that his prescription of diazepam had been reduced to a lower dose which he did not feel to be sufficient; He was charged and bailed to appear at Swansea Magistrates Court at later date and then released to his partner (who he had disclosed in interview to be also suffering from depression and causing him concerns) David was a type 2 diabetic and had alcohol related issues. The following morning David was found dead on the beach near Mumbles Pier. Cause of death was initially given as unascertained by the pathologist in her autopsy report but having heard and seen further evidence including photographic evidence this was changed to drowning: However, It was not possible to establish exactly where when or how he came t0 enter the water. Although the circumstances pointed to deliberate self harm this could not be proven beyond all reasonable doubt: It was not possible to exclude a possible insulin related cause, accident or a deliberate act: No note of intention was found, The evidence does not fully or further disclose the means whereby the cause of death arose to the required standards and an open conclusion was recorded: Although; suicide could not be established to the criminal standard of proof, the circumstances pointed to this as a strong possibility as to how David came to his death:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.