Artist walked in front of train after being admitted to mental health ward

Health staff failed to properly assess a young artist with serious mental health problems before he escaped security in a mental health ward and walked in front of a train, an investigation has found. Robert Jones died after being struck by a passenger train near Newport on September 28, 2019, less than a day after being admitted to the hospital for mental health issues.

The day before his death, Jones had been admitted to St Cadoc’s Hospital in Caerleon after police found him “confused and covered in mud” on the A465 near Abergavenny, miles from his home in west Wales. However, despite having referred the suicide to the police and after two attempts to leave the hospital on Friday, September 27, the health personnel placed him in the lowest level of observation.

The next morning, he bypassed security by escaping through the hall’s community garden before crossing the path of an oncoming train. They killed him instantly.

Read more: Mom ‘absolutely crushed’ after her only son leaves mental health unit and walks in path of oncoming train

Senior Coroner Caroline Saunders said Jones, who was 25 when he died, was a “loving, talented young man with a clear artistic flair” and “a loving son.” She said he had a history of mental health issues that could be “overwhelming” at times.

The night police found Mr Jones walking along the A465, they asked him if he had thoughts of self-harm or suicide, and he replied by talking about a bridge in Haverfordwest. Police arrested Mr. Jones under the Mental Health Act and took him to St Cadoc’s in Caerleon. Saunders said this was the “last and only time” anyone directly asked him about suicidal thoughts or self-harm.

She said Mr. Jones, of Clynderwen, pembrokeshire, had spoken about “hearing voices” at an initial assessment by Eleanor Sparshott, assistant manager of the Bellevue ward at St Cadoc’s Hospital at the time, but that despite police having given information about him discussing a bridge over the that was not asked. suicidal thoughts during the evaluation. The coroner said this should have been done and that failure to do so was an “omission” in the care of Mr. Jones.

Ms. Saunders said that although a Mental Health Act assessment by three doctors at around 4 p.m. thoughts of self-harm. She added that her findings “were not fully documented.”

Shortly after that evaluation, Mr. Jones asked for some “fresh air” and was allowed to leave the hospital building where he tried to open a nearby van and, when asked to stop by staff, began walking down the street. hospital entrance. Hospital staff went looking for Mr. Jones in a nearby alley and after getting him into a car, he climbed out of the car through a window before re-entering and returning to the hospital’s section 136 suite.

Ms Saunders said evidence provided by Julie Heal, a mental health professional and head of Monmouthshire County Council’s social work team, showed that Mr Jones had been found “confused and colluding” during an assessment. additional. Despite giving conflicting answers to questions, she said these concerns were not brought to the attention of staff at the Adferiad mental health unit where he was staying that night. She said an assessment should have explored Mr Jones’s risk of leaving the room, given his attempts to leave that day, and that it was “not possible” to determine his level of risk as concerns had not been adequately conveyed to staff. responsible for making decisions about your care. “This was a flop,” she said, adding that “no obvious consideration was given to Robert’s changeable and unpredictable behavior.”

Ms. Saunders also referred to the decision to place Mr. Jones on level one observation, which meant that he was checked every 30 minutes the night of his stay in the Adferiad unit. She said it had been “premature” to do this and that the level two observation, under which patients are checked every 15 minutes, “should have been enforced”. She said staff claims that Mr. Jones was “calm” during routine observation checks were not based on any assessment made by staff even though the room was not occupied that night.

Mr. Jones was awake around 4:30 a.m. the morning she died, calling his mother and trying to charge his phone at the hospital. He was seen at 7:30 a.m. during a room check, but could not be located by 8:00 a.m. Police were alerted, but it was later confirmed that Mr. Jones had been killed by a passenger train traveling from Cardiff to Crewe at around 8:05am on Saturday 28 September 2019. “If Robert had been on 15 minute observations his departure from the could have been prevented,” the coroner said.

One medical cause of death was recorded as multiple injuries. Offering a narrative conclusion, Ms. Saunders said that Mr. Jones had “suffered from significant mental health problems” and “should have been placed on level two observations” given his references to suicide, self-harm and attempted suicide. leave the room. She said: “Her death of his was a suicide that could have been prevented if he had been put on the proper observation regimen.”

However, Ms Saunders added that “while mistakes were made” and elements of Mr Jones’ care were not carried out properly, they did not amount to negligence on the part of the Aneurin Bevan University Board of Health and there was no lack of policy that would have put Mr. Jones at risk. Noting her family’s concerns about the level of security in the ward, where there had been previous problems with patients escaping through the garden area, Ms Saunders acknowledged that improvements had since been made to the garden. , including improved lighting, alarm systems and CCTV. She said resource issues were “manifold” at the board of health and it was not her role to determine which issues were prioritized and concluded she would not submit a report preventing future deaths.

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