A REPORT into the death of a well-known mental health campaigner in Withybush Hospital has still not been produced by Hywel Dda Health Board, nearly three years after her death, a pre-inquest hearing heard last Friday.

Susan Evans, from Milford Haven, died in the early hours of Monday, November 17, 2014. The 75-year-old was first a patient at the hospital’s Bro Cerwyn centre and then transferred onto the cardiac ward.

Mrs Evans, a mum and grandmother, was a passionate campaigner for mental health advocacy. A collection for Advocacy West Wales after her death raised enough money to fund a young persons’ advocate in Pembrokeshire schools for six months.

Deputy coroner, Gareth Lewis, was told on Friday that, despite assurances by the health board that a root cause analysis report would be produced by mid-September, that report was still not available for either himself or Mrs Evans’ family to see.

An email was sent to the coroner’s office by Blake Morgan, the health board’s solicitors, just one day before the hearing.

Blake Morgan’s Claire Rawle told the hearing that the report, examining the circumstances of Mrs Evans’ death, had now been received by the health board but that the board now needed to undertake further internal investigations.

She assured the coroner that the full report would be available by the end of October at the latest.

Mrs Evans’ family told the deputy coroner that they had concerns about the way that teams at the hospital had communicated and about allegations, from a whistle blower, that medical records had been falsified following Mrs Evans’ death.

Speaking after the inquest Mrs Evans’ sons, Bruce and Bill, told the Western Telegraph: “A report written for Dyfed-Powys Police in March 2016 said that there was a systemic failure on the part of both teams [in Withybush] and a failure of clinical governance.

“The report recommended that a comprehensive review should be undertaken without delay on behalf of the health board.

“The health board has seen the police report and still hasn’t produced its report.

“Our motivation is to push the health board to improve on policies, it’s more likely then that what happened to our mum won’t happen in the future.

“As a family we have had to wait for three years to find out what happened to our mum and why it happened. As far as we are aware there have been no steps taken to learn lessons.”

Deputy coroner Lewis scheduled the inquest for January 18 and 19. He directed that the root cause analysis report must be available.