Hywel Dda Health Board has been issued with a Prevention of Future Death ruling following the recent inquest into the death of Kieran Crimmins.

After listening to evidence from health board representatives throughout the intense five-day hearing, Acting Senior Coroner Paul Bennett said there were 'numerous inconsistencies’ in the weeks leading up to Kieran’s death which Hywel Dda must now address.

Today (Friday) Mr Bennett published a report outlining his reasons for serving the Regulation 28 Report, also known as the 'Prevention of Future Death report', on Hywel Dda.

“One of the objectives of an inquest is to learn lessons from tragedy and whether anything revealed by the investigation creates a risk of other deaths,” said Mr Bennett.

"In this inquest, the anomaly whereby significant steps may have been overlooked remains a concern, and accordingly my duty to make a report on this issue arises.”

One of Hywel Dda’s major shortfalls in Mr Bennett’s report is the lack of communication and information-sharing between primary mental health services and Tier 2 providers.

”Kieran was given ‘safety net advice’ but no other line of communication was available for him to get back into Crisis following his discharge.

“There appears to be no route back to the mental health service except via A&E for someone who remains vulnerable because of their mental state or who is receiving therapy.”

READ MORE for a full report on Kieran Crimmins' inquest 

Mr Bennett also held Hywel Dda accountable for the way in which their information is stored, monitored and subsequently acted upon. During the inquest he was told that Crisis uses a whiteboard and a manual diary to enter information and action points.

“Once they are completed they are crossed out or moved to the next date until they have been actioned,” said Mr Bennett.

“Two actions were not completed prior to Kieran’s discharge and one had even been crossed out, giving the impression it had been dealt with.”

Mr Bennett said that when health officials were questioned as to why these issues hadn’t been addressed, he had heard no evidence on how this would have been achieved.

The final concern raised was the way in which Mr Crimmins had been spoken to over the phone by a health care social worker.

“She could not see him nor appreciate the impact the conversation would have on him, but this was a matter that needed reconsidering for future management.”

Meanwhile the coroner’s decision to impose the Regulation 28 has been welcomed by Kieran Crimmins’ family.

"It is now hoped that this report will assist in bringing about the much needed change to mental health provision in Pembrokeshire and the wider Hywel Dda Health Board so as to ensure that individuals do not believe that suicide is the only option they have,” reads the family statement.

“We have pursued change through this inquest forum, and we hope it will follow. We don’t want Kieran’s death to be just another statistic”.

Following the coroner's statement,  Mandy Rayani, Director of Nursing, Quality and Patient Experience said, "Hywel Dda University Health Board accepts the findings of the coroner's report.

"The health board will now prepare a response to be submitted to the coroner within 56 days of the date of this report, as required, detailing how we will address the concerns raised to improve service, both in terms of safety and quality.

"We offer our sincere apologies to the family of Mr Crimmins for the failures in care identified at the inquest.”