Michael Bryn Jones' family blame missed opportunities in his care for death

A family said there could have been a different outcome if a mentally-ill man who hanged himself after walking away from hospital had been “properly assessed”.

An inquest at Caernarfon heard how Michael Bryn Jones had taken the final bus of the evening on April 2 last year from his Llandudno home to the Hergest Unit at Ysbyty Gwynedd and asked to see a doctor.

He was referred at 12.54am by Hergest psychiatric nurse Robat Wheldon Hughes to the hospital’s emergency department, but left minutes after arriving at 1.23am without seeing anyone.

Two hours later he was captured on CCTV leaving the hospital grounds.

The 38-year-old gardener, who was suffering with anxiety and depression and believed somebody was wanting to kill him, was reported missing and following an extensive search was found hanged in woods at Caerhun, Bangor, on June 21.

Today, at the end of a two-day inquest which heard evidence from 14 witnesses, North Wales assistant coroner Nicola Jones said that having heard of Mr Jones’ paranoia, anxiety and fears of persecution in the preceding days that she was satisfied his death was suicide.

Mrs Jones said Mr Jones had not been given a “sufficient mental state examination” after turning up outside Hergest.

She said: “It seems to me there should have been some encouragement to get him into the unit.”

She said Mr Hughes had not asked if Mr Jones was a patient.

She said that Mr Hughes, who had stepped in to cover for a colleague, wasn’t able to access records showing that he had been to Ysbyty Gwynedd’s emergency department the previous day and recently dischared from Hergest.

Although Mr Hughes had directed Mr Jones to the emergency department (A+E), nobody had accompanied him, said Mrs Jones.

She said: “Michael should never have been allowed to leave that unit and walk to that area on his own because he would not have gone in (to A+E) or did not book in.”

She said that there had been a failing in that nobody from Hergest had told A+E that Mr Jones was on his way.

Mrs Jones said: “He went to this hospital that morning seeking help and assessment and he did not receive it. He went there looking for help and didn’t get it.”

She said: “The failings on April 3 are very serious with missed opportunities to provide help to Michael who was seeking it that night.”

She hoped that the Betsi Cadwaladr health board would learn lessons from a de-brief following the inquest.

Mr Jones’ brother, Mark Walker said: “We hope that it doesn’t happen again to any other family. We are disappointed that there were missed opportunities. Michael went there looking for help. He didn’t go to commit suicide. He went looking for help.

“There were a number of failings. If Michael had been properly assessed, he wouldn’t have gone missing and we wouldn’t have had this situation.”

A Betsi spokesman said: “We offer our sincere condolences to Michael’s family and fully accept the coroners findings following the inquest. We have carried out our own thorough investigation, in conjunction with Michael’s family, and as a result we have made changes to service provision.”