A mental health trust should review its procedures following the sudden death of a 29-year-old father of three, a coroner said.
Daniel Scott Watson hanged himself at his home on Bersham Road, Wrexham on June 5 just days after moving into the address following months of uncertainty about his housing situation.
Mr Watson’s family and former partner, who were present at the inquest held at Wrexham’s Guildhall, said he had been failed by the mental health services and particularly they were critical of the treatment he’d received at Ty Derbyn mental health unit at Wrexham Maelor Hospital.
Recording a narrative conclusion, John Gittins, coroner for North Wales East and Central, said Mr Watson had placed a ligature around his neck but he could not be certain he intended to take his own life.
Mr Gittins said: “There are times when as a coroner I would like a freer reign to speak my mind but I have to tread carefully.
“That said, there appears to me there are some concerns in terms of the treatment Dan received.”
In a statement read to the inquest, the deceased’s grandfather, John Watson, said the family had hoped moving into his new home would be a fresh start for the 29-year-old.
His grandfather described visiting him on Tuesday, May 30 and finding him sitting on the front step “like the king of the castle”, but that was the last time he had seen him.
In the following days his mental well-being had deteriorated, especially after a visit to Wrexham Maelor Hospital on Friday. He was described as “being in bits and tearful and suicidal” claiming staff were not helping him.
Mr Watson was said to have been particularly affected by the decision to reduce his person independence payments from £700 to £400 per month and that his assessment had concentrated on his physical abilities and not his mental issues.
He had been homeless since July 2016 and was also upset by the decision to withdraw his driving license due to the medication he was taking.
The inquest heard Mr Watson had long-standing mental health problems and had been diagnosed with bi-polar in September 2014 and was sectioned twice that year.
He was afraid to go to sleep, scared of being admitted to hospital and had taken to recording phone calls and meetings he had with medical staff.
At one point he had made a ‘den’ by the river and lived there for a short while and he had also suffered from a burst appendix.
He had split up with his partner and the mother of his three children in July 2016 and despite taking different medication he was described as being increasingly paranoid and displaying symptoms of OCD.
His grandfather said a visit to Ty Derbyn on June 2 was “a cry for help that should have been taken seriously”.
“They have let us down, leaving our children without a father,” he added.
A statement from consultant psychiatrist at NHS Wales, John Clifford, said Mr Watson suffered from “flights of ideas” and showed “clear manic symptoms” which were not helped by “continued cannabis use”.
Addressing the inquest, Mr Watson’s social worker, John Griffiths, said that he had first started working with him in December 2016 and that finding him housing was a priority.
“He did not want to live in Caia Park and he had a dog which proved a problem,” said Mr Griffiths.
“He wanted to put roots down for his own stability.”
When questioned by Mr Gittins why Mr Watson was not offered other treatment including cognitive behavioural therapy (CBT), Mr Griffiths replied “there are huge waiting lists.”
He said that Mr Watson would not take his medication due to a fear of side effects and that he would be “crying all day” and not eat well.
“There was a cloud above his head,” said Mr Griffiths. “But he wanted to keep going for his children.”
Mr Griffiths said losing the use of his car was “a big moment” for Mr Watson.
“It is hard with people like Dan as they can be overwhelmingly negative,” he said.
Mr Griffiths conceded that a support worker could have been assigned to Mr Watson to help with things like shopping and housing issues.
“Dan would tell me on a weekly basis that he would kill himself,” said the social worker. “But I don’t have the power to section somebody.”
He added that Mr Watson had also once threatened to use a machete on him.
A staff member at Ty Derbyn confirmed that Mr Watson had attended the Wrexham Maelor Hospital mental health unit with a friend on June 2 and was “very tearful” after attending another department at the hospital.
Mr Griffiths was on leave but they had a 20-minute meeting in which Mr Watson had described how no one was listening to him.
The staff member denied that Mr Watson told him he was suicidal.
A post mortem, carried out by Dr Mark Atkinson, found evidence in Mr Watson’s system of morphine consistent with heroin use and cocaine but gave the cause of death as hanging.
Dr Masood Malik, consultant psychiatrist/clinical director at Betsi Cadwalader University Health Board, said a report into Mr Watson’s death had revealed a number of issues.
These included a failure to update Mr Watson’s treatment plan, poor record keeping and sporadic contact with the patient.
Mr Gittins, said: “This is as damning an investigative report as I’ve seen.”
“It’s very severe,” agreed Dr Malik.
“When you look at the whole picture it should have been ringing alarm bells.”
After reaching a narrative conclusion, Mr Gittins issued a ‘Regulation 28’ notice, which a coroner normally issues when he believes action needs to be taken to prevent further deaths.
He said: “For Mr Griffiths to tell me all he has done since this incident is to have a conversation with his line manager and propose a 20-minute online training exercise, which he has not as yet completed, flies in the face of anything I recognise as being adequate.
“There appears to be missed opportunities in the case of Daniel Watson and I am keen as are the family that similar situations do not occur in the future.”