A NUMBER of failings in mental health care led to the death of a Pembroke man last year, an inquest has heard.

Lance John Kenneth Osborn, 28, of Holyland Drive, Pembroke was found dead by police at the end of May last year following an extensive search near the Cleddau Bridge.

At the inquest into his death on Friday, February 16, the court heard from a spokesperson for Hywel Dda University Health Board, who said the health board fully accepted there were failings in the care of Mr Osborn.

Speaking to the court via conference call, Janet Griffiths said: “I think there were a number of things identified in the report which the health board acknowledges.

“An action plan has been drawn up to address these failings and to ensure change is necessary change is carried out to ensure that this does not happen in the future.”

The coroner for Pembrokeshire, Mark Layton, recorded a narrative conclusion.

Mr Layton said Mr Osborn had entered the Cleddau Estuary on May 31 with the intention of taking his own life.

The cause of death was drowning.

He said:"At the time of death he was in the care of mental health services, and there were failings in the care he received."

He added: “On September 29, 2017, I heard evidence on the circumstances leading to the death of Lance Osborn.

“It became known to me that the family had concerns about the care that Lance had from the health board.”

Mr Layton said screening and allocation discussions about Mr Osborn should have been adequately documented in official records, and staffing issues which led to a delay in referral should have been passed on to management.

“These issues are identified as shortcomings that will now be addressed by the health board in relation to the care of future patients.

“I very much hope the health board and the standards they are setting are maintained for patients in the future.”

A spokesman for Hywel Dda University Health Board said: “We would like to offer our sincere condolences to Mr Osborn’s family for their loss. 

"We fully accept the findings of the coroner, including that there were failings in the care that Mr Osborn received, and we have put together a detailed action plan to address a number of matters that were identified.”

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