concluded an inquest on 28th February 2019 into the passing of Mr Keith Heatley: The medical cause of death was 1a. Drowning and the conclusion of the inquest was an open conclusion:

find the fact that Mr Heatley was admitted voluntarily to hospital on 1s May 2018 and thereafter was transferred t0 Ward 14 on 3r May 2018 find that upon admission that he needed urgent admission and view which accept that at the time of admission on 1st 2018 he was considered a high risk of suicide, potential risk to his wife and possibly psychotic. find the fact that during the time Mr Heatley remained on Ward 14 he enjoyed various amounts and degrees of leave from the hospital grounds. This varied between leave within the hospital grounds and leave outside the hospital grounds with his family find that there was a lack of documented evidence of multidisciplinary decision-making and planning of Mr Heatley s leave from the ward. find that the time of writing the serious incident clinical review there was no policy guidance within the mental health and learning disability delivery unit regarding leave for informal patients_ find as & fact that although multidisciplinary team meetings were held on the 8ih and 15"h of May they were not documented directly in the clinical notes but were instead documented inpro formas intended t0 be added to the clinical record accept the evidence Jthat there was a lack of consistent recording of MDT meetings within the clinical notes particularly for the 8 h and 15th of May 2018. find as a fact that there is no evidence of anyone agreeing or authorising leave for Mr Heatley on 18th 2018 find as a fact that even if there was a decision made to grant and authorise leave Mr Heatley on 18lh May 2018 there was no clinical review of him prior to him leaving the May May hospital that day. find as a fact find the fact that the risk of suicide andlor self-harm was real and ever present: In real terms this simply means that this was not a fanciful whim or suggestion find that Mr Heatley left the family home at some time in the afternoon of 18ih May and thereafter was found in the water. find that Mr Heatley sadly passed away as a result of drowning accept the medical cause of death as propounded by which IS supported by the evidence oi concerning the bloodlwater fluid on the lungs It is not suggested Mr Heatley passed away as result of any other cause There is simply no evidence before me as to how Mr Heatley entered the water find that cannot be satisfied on the evidence that the conclusion of suicide is appropriate or merited. The evidence does not show a causal Iink between those facts as have found In relation to the care and the passing it follows the state could not be in breach of its obligations under article 2 to protect life_ The inquest focused on the leave given to Mr Heatley as a voluntary patient; the systems in place to authorise and review the same and the support given to families_upon a voluntary patient enjoying_home leave: CoRONERS CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern In my opinion there is a risk that future deaths will occur unless action is taken: In the circumstances it is my statutory duty to report to you: The MATTERS OF CONCERN are as follows_ (1) The evidence of a Consultant Psychiatrist who was a Clinical Advisor to a Significant Incident Review stated that there was a policy in England for reviewing and assessing patients who are voluntarily admitted to hospitals before go on home leave. There is no such policy or procedure in Wales: (2) As a result of there no policy in Wales. hospital doctors and Nursing staff are reliant on 'best practice' however this concept is not defined nor does it provide a sufficient level of guidance for patients staff (3) There were no or insufficient procedures in place for hospital staff to Iiaise with the patient's family and CPN when leave is considered t0 examine the preparedness of the family and whether there were systems of support in place_

In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action.