Lucy Jones

I am Caroline Saunders, Senior Coroner for the Area of Gwent

On 29/03/2022 an investigation was opened into the death of Lucy Amanda Jones The investigation concluded at the end of the inquest on: 20/12/2022 The conclusion of the inquest was recorded as: Suicide The medical cause of death was: 1a Asphyxia 1b Hanging 1c) Mental Illness

In 2019 Lucy Amanda Jones developed a serious mental illness which caused her to become stricken with paranoia. Despite receiving treatment and support, the problems she faced became overwhelming and on 12/03/22, Lucy took her own life by hanging [REDACTED] in Abergavenny.

The MATTERS OF CONCERN are as follows:

1. Lucy Amanda Jones was admitted to Talygarn Ward at The County Hospital Pontypool in December 2019 under Section 2 of the Mental Health Act. On discharge from hospital, she was placed on the waiting list for Cognitive Behavioural Therapy (CBT). In evidence provided by her General Practitioner, I was informed that Lucy was still waiting for CBT at the time of her death in March 2022.
2. Following Lucy’s death a concise review of the care she had received from the mental health team was undertaken. The review noted that following a consultant review in January 2022, Lucy was due to be followed up in the community within 2 weeks, but that in fact she was not seen again prior to her death. The Community Psychiatric Nurse (CPN) attempted to make contact by phone on only 2 occasions and did not speak to Lucy. The CPN was apparently reassured by Lucy’s housemate, who had no concerns for Lucy.

No efforts were made to “cold call” when Lucy could not be contacted.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. I should be grateful if the following information be provided to me:

1. The steps that are being taken to ensure that patients who are so unwell to be detained under the Mental Health Act, do not have to wait for more than 2 years for psychological therapies.
2. The policy that determines what steps should be taken to ensure that mental health practitioners can be properly reassured about the health of their patients who are refusing or reluctant to engage.