A narrative conclusion was recorded at an inquest on a troubled 15 year old schoolgirl that she jumped from the Menai suspension bridge, resulting in her death from a ruptured aorta.
It was the end of a two-day inquest at Caernarfon on Josie James, who had recently been discharged from an adolescent mental health unit.
The inquest had heard Josie had spoken about suicide and said she had “murderous thoughts towards herself.”
Assistant coroner Nicola Jones explained that she was going to move away from a suicide conclusion because it was not known what was her state of mind when she leapt from the suspension bridge in August 2015.
However it was clear that there was ineffective communication with Josie’s family – parents Peter and Joy James, of Clwt y Bont, near Caernarfon – about her assessment, diagnosis, a change in medication or that she had refused medication.
The team at the Abergele unit was fond of Josie, described as bright and clever, but it had not been explained sufficiently to the parents what should be done in the event of worrying changes after her discharge from the unit. Nor was there an emergency phone number for Josie nor her parents to call for advice.
The assistant coroner said it would be speculating to say whether had there been better communication the outcome would have been any different. Mrs Jones said she would not make a Rule 28 declaration against the health authority relating to the prevention of future deaths because she had been assured the service was improving and they were listening to families.
During her evidence Mrs Joy James told the coroner : “As a family we have no interest in pointing the finger at any individual. We just want lessons to be learned.”
In a statement after Wednesday’s hearing the Betsi Cadwaladr health board offered sincere condolences to the family.
It added: “We acknowledge that there was no effective communication with her family.
“We are working hard to improve the way we work with families, which includes ensuring they are supplied with treatment plans and additional information and advice to support the ongoing care of our service users.
“We now ensure that families of service users can access our intensive community treatment team, which can provide further advice and guidance, and we ask families how they wish to be communicated with when service users are admitted.
“We have also set up a user group made up of service users, their families and our clinicians, which helps us to listen and learn about how to make significant, meaningful improvements to the care we provide.”