There is a "significant risk of future deaths" unless concerns over mental health risk assessments in Pembrokeshire are addressed, a senior coroner has warned.
The warning follows the death of Pembrokeshire man Trevor Anthony Evans, which prompted an inquest and a Prevention of Future Deaths report.
Gareth Lewis, Senior Coroner for Carmarthenshire and Pembrokeshire, issued the warning after concluding that Mr Evans, 54, died by suicide at his home on Whitehall Drive, Pembroke, on February 27, 2020, while experiencing significant mental health difficulties.
The inquest, held over five days in April this year, examined Mr Evans' interactions with police, ambulance crews, mental health professionals, and other healthcare staff in the days leading up to his death.
Concerns about his mental health had been raised by his family, police, and the ambulance service, leading to an emergency referral from his GP for a mental health assessment.
On February 24, 2020, Mr Evans was assessed by a community mental health nurse.
The coroner found there had been an "over reliance" on what Mr Evans told the nurse, a failure to review medical records and insufficient investigation of background information which was available.
Critical information was missed, including recent police and ambulance involvement, concerns raised by family members, previous suicide attempts, and prior contact with the Crisis Response Home Treatment Team.
Mr Lewis concluded that, with hindsight, a referral to the Mental Health Crisis Team would have been appropriate if the readily accessible information had been reviewed.
The inquest heard from the Senior Nurse for Pembrokeshire Adult Community Mental Health Service, who said that a more robust system was now in place.
This included an aide-memoire to help staff systematically collect information from referrers.
However, Mr Lewis said he was concerned about continuing to place the onus on referrers to provide complete information, warning that assessments could still be "incomplete, perfunctory and inadequate" under this approach.
He called for a more collaborative, information-seeking culture within mental health services.
The coroner’s Prevention of Future Deaths report, dated May 11, was sent to Hywel Dda University Health Board.
Liz Carroll, service director mental health and learning difficulties clinical care group, said: "While we cannot comment on individual patients, we extend our deepest sympathies to the family and loved ones who continue to deal with their loss.
"The Health Board is always grateful to the Coroner for bringing matters of concern to our attention and we always carefully review the circumstances surrounding the death of a patient under our care and identify areas where care fell below the standards we expect.
"We use this learning to strengthen our systems, processes and clinical oversight.
"Recent work includes a number of improvements designed to strengthen information gathering, risk assessment and inter-agency communication.
"The Health Board has implemented a person-centred safety planning approach across services, initially within inpatient settings and now extending into community services.
"The approach supports collaborative assessment and management of risk through active engagement with service users and their support networks.
"We are continuing to deliver Wales Applied Risk Research Network (WARRN) training across mental health services.
"The training explicitly promotes professional curiosity, collaborative working and shared responsibility for risk assessment and management.
"As well as this we have been actively engaged in a national programme of work aligned to the Open Access Mental Health Support Model, focused on strengthening approaches to risk, safety and system-wide responsibility for managing risk.
"The Health Board remains committed to continuous learning and improvement to reduce the risk of future deaths and improve the safety of those accessing mental health services."
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