Robert Smith
PFD Report
All Responded
Ref: 2025-0240
Mental Health related deaths
Suicide (from 2015)
Wales prevention of future deaths reports (2019 onwards)
All 1 response received
· Deadline: 16 Jul 2025
Response Status
Responses
1 of 1
56-Day Deadline
16 Jul 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
1. The guidance provided to clinicians and nursing staff within the mental health services as to when information and sharing and information gathering was to be undertaken with, and from, family members and how such decisions are to be recorded on the standard forms lacked clarity, particularly as regards the distinction between information sharing and information gathering. Such guidance being of relevance when a patient has given consent for information sharing and gathering to take place and when, and in what circumstances, such steps would be taken.
2. The information leaflet provided to patients lacked sufficient detail of the approach taken by mental health services on the issue of information sharing and information gathering so that patients could readily understand the difference between the two and understand when the need for information sharing and/or gathering could arise and what steps would be taken by mental health services.
2. The information leaflet provided to patients lacked sufficient detail of the approach taken by mental health services on the issue of information sharing and information gathering so that patients could readily understand the difference between the two and understand when the need for information sharing and/or gathering could arise and what steps would be taken by mental health services.
Responses
The Health Board has co-produced values-based guidance with families on information sharing and gathering, which will be finalized. They commit to reviewing and updating the patient information leaflet, reviewing documentation practices, and developing a bespoke training programme for mental health staff. A co-produced family engagement project also started in May 2025.
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Dear Mr Morse
Re: Regulation 28 Report to Prevent Future Deaths – Robert Maxwell Smith
Thank you for your report dated 21 May 2025 concerning the tragic death of Mr. Robert Maxwell Smith. We acknowledge the concerns raised during the inquest and are committed to taking appropriate actions to prevent future occurrences.
Response to Coroner’s Concerns:
Guidance on Information Sharing and Gathering:
We recognise the need for clearer guidance for clinicians and nursing staff regarding information sharing and gathering with family members. During June and July 2025, we have worked with families, carers, service users and clinicians to co-produce values-based guidance to ensure that the distinction between information sharing and information gathering is clearly defined and understood. The guidance will include examples of lived experience in the form of quotes from families and service users and will include detailed instructions on when and how to document these interactions on standard forms.
Patient Information Leaflet:
We agree that the current patient information leaflet lacks sufficient detail on the approach to information sharing and gathering. During June and July 2025, we have worked with families, carers, service users and clinicians to co-produce a leaflet which will provide comprehensive information so that patients can easily understand the differences and the circumstances under which information sharing and gathering will occur. This will help ensure that patients are fully informed about the Eich cyf/Your ref: Ein cyf/Our ref: SR-jtf-0725-118 Welsh Health Telephone Network: Direct Line/Llinell uniongychol: 029 2183 6010 Executive Headquarters / Pencadlys Gweithredol
Woodland House
Ty Coedtir Maes-y-Coed Road
Ffordd Maes-y-Coed Cardiff
Caerdydd CF14 4HH
CF14 4HH
Bwrdd Iechyd Prifysgol Caerdydd a’r Fro yw enw gweithredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Health Board
Croesawir y Bwrdd ohebiaeth yn Gymraeg neu Saesneg. Sicrhawn byddwn yn cyfathrebu â chi yn eich dewis iaith. Ni fydd gohebu yn Gymraeg yn creu unrhyw oedi The Board welcomes correspondence in Welsh or English. We will ensure that we will communicate in your chosen language. Correspondence in Welsh will not lead to a delay
processes and their rights. We recognise that families, carers, and significant others often play a key role in service users care and we are therefore also developing a family and carer information leaflet.
Action Plan:
Revision of Guidance:
We have established a working group with involvement from families, carers, service users and clinicians to review and revise the existing guidance. The revised guidance will be disseminated to all relevant staff members through training sessions and internal communications. We aim to complete this process by October 2025.
Updating Patient Information Leaflet:
The updated leaflet will be developed by a panel of experts, including mental health professionals, families, carers, and service users, to ensure that it is values based, has clarity and is comprehensive. We plan to have the new leaflet available for distribution by October 2025.
Training and Awareness:
We will conduct mandatory training sessions for all mental health service staff to ensure they are fully aware of the revised guidance and the importance of accurate documentation. These sessions will start in October 2025.
Information Sharing and Suicide Prevention:
We have included information regarding the UK Government, Department of Health information sharing and suicide prevention: consensus statement" within the guidance. This statement emphasises the importance of sharing information within the context of relevant laws and professional judgment to prevent suicide.
Communication to Managers and Staff:
We will discuss the theme of information sharing and gathering at the MHCB (Mental Health Clinical Board) Professional Learning Event and Shared Learning Event in September 2025.
Co-produced Family Engagement Project:
The Mental Health Clinical Board has commissioned a co-produced family engagement project. This project started in May 2025 and aims to support a cultural shift in practice to enhance family engagement and involvement. The project will complement existing initiatives across the Mental Health Clinical Board which prioritise and encourage family engagement, particularly those based on co- productive and compassionate care. Due to the nature of co-production work, whilst there is an anticipated time of two years for the project, this needs to be agreed with the project working group.
Bwrdd Iechyd Prifysgol Caerdydd a’r Fro yw enw gweithredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Health Board
Croesawir y Bwrdd ohebiaeth yn Gymraeg neu Saesneg. Sicrhawn byddwn yn cyfathrebu â chi yn eich dewis iaith. Ni fydd gohebu yn Gymraeg yn creu unrhyw oedi The Board welcomes correspondence in Welsh or English. We will ensure that we will communicate in your chosen language. Correspondence in Welsh will not lead to a delay
We are committed to implementing these changes promptly and effectively to enhance the safety and well-being of our patients. We will provide a detailed update on the progress of these actions by the deadline of 16 July 2025.
Thank you for bringing these critical issues to our attention. We are dedicated to improving our services and preventing future tragedies.
Re: Regulation 28 Report to Prevent Future Deaths – Robert Maxwell Smith
Thank you for your report dated 21 May 2025 concerning the tragic death of Mr. Robert Maxwell Smith. We acknowledge the concerns raised during the inquest and are committed to taking appropriate actions to prevent future occurrences.
Response to Coroner’s Concerns:
Guidance on Information Sharing and Gathering:
We recognise the need for clearer guidance for clinicians and nursing staff regarding information sharing and gathering with family members. During June and July 2025, we have worked with families, carers, service users and clinicians to co-produce values-based guidance to ensure that the distinction between information sharing and information gathering is clearly defined and understood. The guidance will include examples of lived experience in the form of quotes from families and service users and will include detailed instructions on when and how to document these interactions on standard forms.
Patient Information Leaflet:
We agree that the current patient information leaflet lacks sufficient detail on the approach to information sharing and gathering. During June and July 2025, we have worked with families, carers, service users and clinicians to co-produce a leaflet which will provide comprehensive information so that patients can easily understand the differences and the circumstances under which information sharing and gathering will occur. This will help ensure that patients are fully informed about the Eich cyf/Your ref: Ein cyf/Our ref: SR-jtf-0725-118 Welsh Health Telephone Network: Direct Line/Llinell uniongychol: 029 2183 6010 Executive Headquarters / Pencadlys Gweithredol
Woodland House
Ty Coedtir Maes-y-Coed Road
Ffordd Maes-y-Coed Cardiff
Caerdydd CF14 4HH
CF14 4HH
Bwrdd Iechyd Prifysgol Caerdydd a’r Fro yw enw gweithredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Health Board
Croesawir y Bwrdd ohebiaeth yn Gymraeg neu Saesneg. Sicrhawn byddwn yn cyfathrebu â chi yn eich dewis iaith. Ni fydd gohebu yn Gymraeg yn creu unrhyw oedi The Board welcomes correspondence in Welsh or English. We will ensure that we will communicate in your chosen language. Correspondence in Welsh will not lead to a delay
processes and their rights. We recognise that families, carers, and significant others often play a key role in service users care and we are therefore also developing a family and carer information leaflet.
Action Plan:
Revision of Guidance:
We have established a working group with involvement from families, carers, service users and clinicians to review and revise the existing guidance. The revised guidance will be disseminated to all relevant staff members through training sessions and internal communications. We aim to complete this process by October 2025.
Updating Patient Information Leaflet:
The updated leaflet will be developed by a panel of experts, including mental health professionals, families, carers, and service users, to ensure that it is values based, has clarity and is comprehensive. We plan to have the new leaflet available for distribution by October 2025.
Training and Awareness:
We will conduct mandatory training sessions for all mental health service staff to ensure they are fully aware of the revised guidance and the importance of accurate documentation. These sessions will start in October 2025.
Information Sharing and Suicide Prevention:
We have included information regarding the UK Government, Department of Health information sharing and suicide prevention: consensus statement" within the guidance. This statement emphasises the importance of sharing information within the context of relevant laws and professional judgment to prevent suicide.
Communication to Managers and Staff:
We will discuss the theme of information sharing and gathering at the MHCB (Mental Health Clinical Board) Professional Learning Event and Shared Learning Event in September 2025.
Co-produced Family Engagement Project:
The Mental Health Clinical Board has commissioned a co-produced family engagement project. This project started in May 2025 and aims to support a cultural shift in practice to enhance family engagement and involvement. The project will complement existing initiatives across the Mental Health Clinical Board which prioritise and encourage family engagement, particularly those based on co- productive and compassionate care. Due to the nature of co-production work, whilst there is an anticipated time of two years for the project, this needs to be agreed with the project working group.
Bwrdd Iechyd Prifysgol Caerdydd a’r Fro yw enw gweithredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Health Board
Croesawir y Bwrdd ohebiaeth yn Gymraeg neu Saesneg. Sicrhawn byddwn yn cyfathrebu â chi yn eich dewis iaith. Ni fydd gohebu yn Gymraeg yn creu unrhyw oedi The Board welcomes correspondence in Welsh or English. We will ensure that we will communicate in your chosen language. Correspondence in Welsh will not lead to a delay
We are committed to implementing these changes promptly and effectively to enhance the safety and well-being of our patients. We will provide a detailed update on the progress of these actions by the deadline of 16 July 2025.
Thank you for bringing these critical issues to our attention. We are dedicated to improving our services and preventing future tragedies.
Action Should Be Taken
7 YOUR RESPONSE
Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862 You are under a duty to respond to this report within 56 days of the date of this report, namely by 16th July 2025. Only I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862 You are under a duty to respond to this report within 56 days of the date of this report, namely by 16th July 2025. Only I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
Report Sections
Investigation and Inquest
On 30 October 2023 I commenced an investigation into the death of Robert Maxwell SMITH . The investigation concluded at the end of the inquest 07/05/2025 . The conclusion of the inquest was Suicide.
1a Pressure On Neck, Consistent With Hanging 1b 1c II 4 CIRCUMSTANCES OF THE DEATH:
Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862 These were recorded as follows Robert Maxwell Smith died on 26th October 2023 at , Cardiff. Mr Smith died by hanging . It is more likely than not that he intended the consequences of his action to result in his own death. Mr Smith had recent contact and intervention from mental health services and was known to be at risk of suicide due to a deterioration in his mental health presentation over the preceding weeks. Mental heath services did not inform Mr Smith’s wife of the extent of his suicidal ideations. Mr Smith had indicated that he would inform his wife of his raised suicidal ideations but did not do so. On balance, it cannot be said that if such information had been provided, Mr Smith’s suicide would have been prevented. Conclusion: Suicide
1a Pressure On Neck, Consistent With Hanging 1b 1c II 4 CIRCUMSTANCES OF THE DEATH:
Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862 These were recorded as follows Robert Maxwell Smith died on 26th October 2023 at , Cardiff. Mr Smith died by hanging . It is more likely than not that he intended the consequences of his action to result in his own death. Mr Smith had recent contact and intervention from mental health services and was known to be at risk of suicide due to a deterioration in his mental health presentation over the preceding weeks. Mental heath services did not inform Mr Smith’s wife of the extent of his suicidal ideations. Mr Smith had indicated that he would inform his wife of his raised suicidal ideations but did not do so. On balance, it cannot be said that if such information had been provided, Mr Smith’s suicide would have been prevented. Conclusion: Suicide
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.