Gareth Williams
PFD Report
All Responded
Ref: 2022-0270
Mental Health related deaths
Suicide (from 2015)
Wales prevention of future deaths reports (2019 onwards)
All 1 response received
· Deadline: 29 Nov 2022
Coroner's Concerns (AI summary)
The deceased fell between two non-communicating care teams (mental health and ENT), leading to insufficient support and an inability to resolve his complex health problems.
View full coroner's concerns
Gareth Williams found himself in a no-win situation. His mental health could not be improved without a resolution to his hearing problems and his tinnitus was untreatable. During the course of his treatment, Gareth was regularly transferred back to the "other" team, being told that either mental health or ENT was the most appropriate speciality. I found that Gareth was left without sufficient support, falling between 2 teams, who did not directly communicate with each other.
Responses
Action Planned
Aneurin Bevan University Health Board is expanding a service called 'Adferiad' to include people with other medical and long-term conditions, which will be delivered by a multi-disciplinary team including medical, nursing, and Allied Health Professionals to improve interdisciplinary working between physical and mental health specialties. (AI summary)
Aneurin Bevan University Health Board is expanding a service called 'Adferiad' to include people with other medical and long-term conditions, which will be delivered by a multi-disciplinary team including medical, nursing, and Allied Health Professionals to improve interdisciplinary working between physical and mental health specialties. (AI summary)
View full response
Dear Ms Saunders Re: Regulation 28 Report received by Aneurin Bevan University Health Board further to the inquest touching on the death of Gareth Williams concluded on 17.08.2022 I am writing to provide you with the Health Board’s response to the Regulation 28 Report to Prevent Future Deaths, following the inquest into the death of Mr Gareth Williams. As requested, the information presented below is intended to describe the action taken / being taken to mitigate the risk of future deaths. You require the Health Board to provide you with the following information:
1. Whether the Health Board intends to undertake a review into the circumstances surrounding the death of Mr Williams, and
2. Confirm the steps which will be taken to ensure that there is better interdisciplinary working between physical and mental health specialities in the future A ‘concise review’ was undertaken by the Mental Health and Learning Disabilities Division of the Health Board when we became aware of Mr Williams’ death. Since that time, we have had the opportunity to review the wider input of other specialties and understand what services might have supplemented the offers of treatment and intervention available to Mr Williams, in addition to the liaison with the ENT department undertaken by a community mental health nurse with and for Mr Williams. Bwrdd Iechyd Prifysgol Aneurin Bevan Aneurin Bevan University Health Board Pencadlys, Headquarters Ysbyty Sant Cadog St Cadoc’s Hospital Ffordd Y Lodj Lodge Road Caerllion Caerleon Casnewydd Newport De Cymru NP18 3XQ South Wales NP18 3XQ Ffôn: 01633 436700 Tel No: 01633 436700 E-bost: abhb.enquiries@wales.nhs.uk Email: abhb.enquiries@wales.nhs.uk Bwrdd Iechyd Prifysgol Aneurin Bevan yw enw gweithredol Bwrdd Iechyd Lleol Prifysgol Aneurin Bevan Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board
The Health Board acknowledges that its organisational structure has historically, not naturally lent itself well to easy and timely communication between its multiple specialties and disciplines across the Divisions. I am pleased to share that Welsh Government has confirmed that a Health Board service - ‘Adferiad’ - originally developed for people experiencing the effects of ‘Long Covid’ will be receiving substantive, recurrent funding from April 2023 which will also allow it to broaden its inclusion criteria to people with other medical and long-term conditions for whom there are no existing care pathways. This service will be delivered by a team of medical, nursing and Allied Health Professionals – including Health and Clinical Psychologists, thus offering a multi-disciplinary perspective from the point of referral and for consultation to other disciplines & specialties. Part of the expansion of the service will be to map existing services to ensure the person is on the ‘right’ pathway, with a ‘bespoke’ approach to each person’s needs. It is anticipated that people with co-morbidities and needs such as Mr Williams could be referred to Adferiad. The new team will provide expertise upfront in terms of assessment and planning care. The team would develop an individualised recovery and rehabilitation plan with individuals. I trust that this information assures you of the Health Board’s plans to improve interdisciplinary working between physical and mental health specialties in the future. If any further information or assurance is required, please do not hesitate to contact me.
1. Whether the Health Board intends to undertake a review into the circumstances surrounding the death of Mr Williams, and
2. Confirm the steps which will be taken to ensure that there is better interdisciplinary working between physical and mental health specialities in the future A ‘concise review’ was undertaken by the Mental Health and Learning Disabilities Division of the Health Board when we became aware of Mr Williams’ death. Since that time, we have had the opportunity to review the wider input of other specialties and understand what services might have supplemented the offers of treatment and intervention available to Mr Williams, in addition to the liaison with the ENT department undertaken by a community mental health nurse with and for Mr Williams. Bwrdd Iechyd Prifysgol Aneurin Bevan Aneurin Bevan University Health Board Pencadlys, Headquarters Ysbyty Sant Cadog St Cadoc’s Hospital Ffordd Y Lodj Lodge Road Caerllion Caerleon Casnewydd Newport De Cymru NP18 3XQ South Wales NP18 3XQ Ffôn: 01633 436700 Tel No: 01633 436700 E-bost: abhb.enquiries@wales.nhs.uk Email: abhb.enquiries@wales.nhs.uk Bwrdd Iechyd Prifysgol Aneurin Bevan yw enw gweithredol Bwrdd Iechyd Lleol Prifysgol Aneurin Bevan Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board
The Health Board acknowledges that its organisational structure has historically, not naturally lent itself well to easy and timely communication between its multiple specialties and disciplines across the Divisions. I am pleased to share that Welsh Government has confirmed that a Health Board service - ‘Adferiad’ - originally developed for people experiencing the effects of ‘Long Covid’ will be receiving substantive, recurrent funding from April 2023 which will also allow it to broaden its inclusion criteria to people with other medical and long-term conditions for whom there are no existing care pathways. This service will be delivered by a team of medical, nursing and Allied Health Professionals – including Health and Clinical Psychologists, thus offering a multi-disciplinary perspective from the point of referral and for consultation to other disciplines & specialties. Part of the expansion of the service will be to map existing services to ensure the person is on the ‘right’ pathway, with a ‘bespoke’ approach to each person’s needs. It is anticipated that people with co-morbidities and needs such as Mr Williams could be referred to Adferiad. The new team will provide expertise upfront in terms of assessment and planning care. The team would develop an individualised recovery and rehabilitation plan with individuals. I trust that this information assures you of the Health Board’s plans to improve interdisciplinary working between physical and mental health specialties in the future. If any further information or assurance is required, please do not hesitate to contact me.
Part of a Series
2 separate reports were issued from this inquest, each sent to different organisations.
-
2019-0464
Sent to: Newport County CouncilNo responses yet
This report (2022-0270) is shown above.
Sent To
- Aneurin Bevan University Heath Board
Response Status
Linked responses
1 of 1
56-Day Deadline
29 Nov 2022
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
Report Sections
Investigation and Inquest
On 2/9/2021 an investigation was opened into the death of Gareth WILLIAMS The investigation concluded at the end of the inquest on: 17/8/22 The conclusion of the inquest was recorded as: Suicide The medical cause of death was: la) Suspension by ligature 2 Tinnitus
Circumstances of the Death
Gareth Williams was a 45-year-old man who had a history of sensorineural hearing loss and intermittent tinnitus dating back to 2005. He was also treated for depression and insomnia. In early 2021 the situation deteriorated. Gareth's tinnitus worsened but despite being thoroughly examined by the ENT team there was no physiological problem that could be treated.
As a result, Gareth's mental health went into decline. He suffered worsening depression and was referred to the mental health team after he started having suicidal thoughts and indeed acting these out. Written evidence from the Consultant Psychiatrist treating Gareth, stated Gareth was not clinically depressed, although evidence also indicated that he had low mood, was expressing hopelessness and experienced suicidal thoughts. Gareth was discharged from the mental health team because he had no recognisable mental illness. On 23/8/21, Gareth was discovered hanging in Abergavenny. Emergency services attended but Gareth could not be revived. His death being confirmed at 15:27 hours.
As a result, Gareth's mental health went into decline. He suffered worsening depression and was referred to the mental health team after he started having suicidal thoughts and indeed acting these out. Written evidence from the Consultant Psychiatrist treating Gareth, stated Gareth was not clinically depressed, although evidence also indicated that he had low mood, was expressing hopelessness and experienced suicidal thoughts. Gareth was discharged from the mental health team because he had no recognisable mental illness. On 23/8/21, Gareth was discovered hanging in Abergavenny. Emergency services attended but Gareth could not be revived. His death being confirmed at 15:27 hours.
Action Should Be Taken
I should be grateful if the following information be provided to me: Whether Aneurin Bevan University Health Board intend to undertake a review into the circumstances surrounding the death of Gareth Williams and confirm the steps which will be taken to ensure that there is better interdisciplinary working between physical and mental health specialities in the future.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.