UK Inquiry Tracker

Christopher Roberts

PFD Report Historic (No Identified Response) Ref: 2017-0283

Date of Report 5 October 2017

Coroner Aled Gruffydd

Coroner Area Swansea, Neath and Port Talbot

Response Deadline ✓ from report 30 November 2017

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

Care plan reviews lacked documentation, making it impossible to confirm outcomes or whether previous suicide attempts were considered. Additionally, Nomad trays might be unsuitable for certain patients, impeding medication benefits.

View full coroner's concerns

In the circumstances it is my statutory to report to you: _ The care plan review was not recorded which would not allow another person reviewing the file to ascertain that a care plan review had taken place and what the outcome of that review was. It was also the case that a lack of documentation would not demonstrate whether CMHT had considered the matter of the attempt on his own life by the deceased in the weeks leading up to that review, when considering whether to amend or retain the care plan in place at the time: Nomad trays may be unsuitable in dispensing medication to some patients, which may deprive them of the benefits in taking that medication:

Sent To

Swansea Bay University Health Board

Response Status

Linked responses 0 of 1

56-Day Deadline 30 Nov 2017

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 8th January 2016 commenced an investigation into the death of Christopher John Llewellyn Roberts_ The investigation concluded at the end of the inquest on 4 October 2017 . The medical cause of death is 1a opiate toxicity The conclusion of the inquest as how Mr Roberts came to his death is a narrative one and is as follows:- The deceased died of overdose of prescription medication. The intent to take his own life could not be proven to the required standard.

Circumstances of the Death

The deceased was Christopher Roberts and he was pronounced dead on the 19h of October 2015 at his home address of 57 St Nicholas Square, Swansea Marina, Swansea. The cause of death was a deliberate overdose of his pain relieving opiate prescription medicine, MST Continus, with 498mcg/L of morphine being found in his blood by way of a toxicology report Christopher was receiving treatment for mental illness by the Community Mental Health Team (CMHT): Christopher was diagnosed as having a depression and anxiety coupled with borderline personality traits. Christopher's care plan was written in February 2014 and a review was planned for February 2015 The evidence of the Community

Psychiatric Nurse (CPN) was that the review had been carried out with no changes to the care plan; however this was never recorded. Shortly before the care plan was due to be reviewed , Christopher made an attempt on his life by way of overdose: There was no evidence or decision making trail to confirm whether this issue was considered when deciding if the care plan should remain the same. The care plan stipulated that the deceased was responsible for his medication and that this would be administered by way of a dossiette (or nomad tray) and would be prepped on a weekly basis_ The evidence was that the deceased's medication regime was chaotic with tablets taken in the wrong order or not taken at all. This was known to CMHT by way of reports from the deceased's support worker; and from admissions by the deceased himself.

Action Should Be Taken

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

Inquest Conclusion

- The deceased died of overdose of prescription medication. The intent to take his own life could not be proven to the required standard.