Hywel Dda Health Board could be subjected to a Regulation 28 report following a series of inconsistencies in the way in which they supported a 'vulnerable' man who took his own life.

The family of Kieran Crimmins, the 21-year-old who took his own life days after being discharged by the Crisis mental health team, has now urged Pembrokeshire coroner Paul Bennett to impose a Regulation 28 report on the Board to prevent similar deaths from taking place in the future.

Regulation 28 can be imposed by a coroner against an individual or organisation if he believes action should be taken to prevent similar deaths from occurring.


Mr Crimmins took his life on the night of March 26, 2019.

Three weeks earlier he had been discharged by the Crisis team despite displaying suicidal thoughts and attempting to take his life on February 27.

The inquest heard that he had expressed suicidal thoughts on a number of previous occasions.

On Friday, July 8, after recording a verdict of suicide into Mr Crimmins' death, Paul Bennett was asked by the family’s counsel to instigate the Regulation 28 Report on the Hywel Dda Health Board.

“We’re extremely grateful that senior members of Hywel Dda management are present today, listening and taking notes,” said barrister Ben Blakemore.

 “That's all very well. But how are they dealing with the problem?"

During the five day inquest, Mr Bennett heard evidence from a number of Hywel Dda health care workers concerning the way in which they cared for Kieran in the days and weeks leading up to his death.

However, during his conclusion earlier today, Mr Bennett referred to some serious inconsistencies in their delivery.

“The question at stake here is that of how Kieran’s health was monitored he said. “And it’s a fact that care co-ordination did not happen.”

He went on to describe some of the witness evidence as ‘vague’ and questioned the ‘inconsistencies’ which were displayed in the health team's diary.

He referred to a diary entry on March 2 which stated that details of Kieran’s medication had been sent to his GP.

However there was no evidence with his GP to confirm that he had received this notification. When questioned about this, Mr Crimmins' health worker, Miss Hamilton, was unable to explain how and why this had happened.

“The diary inconsistencies highlight a significant flaw in the diary system,” he said. "This gives me cause for concern.”

Mr Bennett also raised concern in the way in which some of Kieran’s care had been provided over the phone rather than in person, given his psychological illness and vulnerability.

Kieran, who lived in Blackbridge Crescent, Milford Haven, had been under the care of Hywel Dda’s mental health teams since he was a child and had presented to Withybush hospital on a number of occasions seeking assistance.

Expert evidence provided to the inquest confirmed that his complex needs made him vulnerable.

Kieran had become a father in 2017 and the inquest heard how his daughter, described as his ‘little princess’, brought a great deal of hope and positivity to his life.

However his psychological needs and maladaptive coping mechanisms contributed to his inability to deal with the extreme fluctuations in his mental health.

“Kieran’s family did not feel listened to nor recognised when begging for the intervention that he so desperately needed,” commented barrister Ben Blakemore following Friday’s verdict.

“The mental health provision in Pembrokeshire and the wider Hywel Dda Health Board is long overdue a review to ensure that individuals do not believe that suicide is the only option they have.

“Kieran’s family has pursued change through this inquest forum, and they hope that his death must not be allowed to be just another statistic.

"Change is needed to avoid more people with vulnerabilities and thoughts such as those Kieran suffered, from losing their lives and of more families going through this hollow hell.

“Suicide is preventable.”

Following Mr Blakemore's submission, Coroner Paul Bennett agreed to carry out an investigation into the family’s request for the Regulation 28. His findings are expected to be delivered next week.