There were ‘missed opportunities’ in the care of a kind and thoughtful Pembrokeshire father in the weeks leading up to his death an inquest has found.
George Edward Chaloner, 31, was described by his siter Ellen as "incredibly beautiful, thoughtful kind and intelligent".
She told an inquest today (Friday, May 29), that in the months leading up to his death Mr Chaloner, who was awaiting final assessments for autism and ADHD, had experienced a severe mental health crisis.
In three months his family wrote to 11 different services trying to get him help.
In April 2023, his mother wrote to the county’s autism services in desperation, describing how her son was scared and becoming suicidal, he was starving and barricaded in his own home.
He was referred to the local primary mental health support service (LPMHSS) and had an initial telephone appointment on May 15, 2023, with a follow up appointment a week later.
Mr Chaloner said that he did not want any of the information from the appointments shared with his family.
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In the space between the two appointments Mr Chaloner’s mental health had deteriorated significantly and he was thinking about suicide more. He was referred to the community mental health team (CMHT) on May 22.
At a meeting the following day the referral was accepted, and it was recommended that he be visited at home by a consultant psychiatrist.
However, Mr Chaloner did not even receive an appointment letter until June 18, with his appointment not scheduled until September.
The inquest heard that national guidelines specified that patients presenting in the way Mr Chaloner did should have been see within a four-week period.
Giving evidence at the inquest, expert witness Dr Laurence Mynors-Wallis, a consultant psychiatrist, said that there was an ‘unacceptable delay’ both in Mr Chaloner receiving the appointment letter and in the date of the appointment.
He added that in light of that delay there should have been further checks on Mr Chaloner in the interim period.
Just eleven days after receiving his appointment letter, Mr Chaloner was found dead in his Haverfordwest flat.
His sister told the inquest that she believed that he may have read the letter and thought: "I can’t wait ten more weeks".
Dr Mynors-Wallis told the inquest that at an initial appointment with the CMHT a care plan and a safety plan would have been explored.
Although these would have taken more appointments to complete, the basic structure would have been in place and would have provided Mr Chaloner with strategies and support.
He added that a review of medication would also have taken place. Mr Chaloner had been prescribed Mirtazapine by his GP but was not taking it.
Dr Mynors-Wallis said that the medication would have helped with Mr Chaloner’s problems sleeping and also helped with his lack of appetite. He said that the anti-anxiety effects of the medication would have begun fairly quickly even if the anti-depressant effect had taken up to two weeks.
The expert witness also said that it was best practice to negotiate with a patient when they said that they didn’t want information shared with their family. That it may be possible to agree to sharing referrals and appointment dates, without disclosing more sensitive information, so that the patient could be supported by their family.
Coroner Mark Layton summarised that Mr Chaloner’s family had done all they could to get him help. He added that the ‘GP could not have done more’ and that Dr Mynors-Wallis was "full of praise" for the way LPMHSS had handled the case.
However, he said that problems arose when the referral was accepted by the CMHT.
“My view is at that point things did go in the way they should not,” he said.
“The way they didn’t go as well as they should is that there was a delay described by the expert as an ‘unacceptable delay’.
“While all the care and safety plans would not have been complete, they would have been under construction.
“Perhaps that in itself would have would have brought hope back to George, knowing that things were moving in the right direction and being done.
“The sense of hopelessness may have diminished if he has seen a glimmer of hope, which he did not see.”
Mr Layton recorded a narrative conclusion, documenting that Mr Chaloner died of hanging and that in the period leading up to his death he struggled with anxiety and depression, aggravated by long standing difficulties with ADHD and autism.
He said a delay in seeing the CMHT had led to ‘missed opportunities to provide a care plan and a safety plan’ as well as medication.
Mr Layton asked Hywel Dda University Health Board to provide information on waiting times for CMHT appointments and also whether best practice was being followed on negotiations around confidentiality.
He said that once he had received these, he would consider whether he needed to compile a prevention of future deaths report.
“All we want out of this is to see that this doesn’t happen again,” said Mr Chaloner’s family.
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