Andrew Shambrook

I am John Adrian Gittins, Senior Coroner for North Wales (East and Central)

On the 28th of March 2022 I commenced an investigation into the death of Andrew John Shambrook (DOB 17.2.77 DOD 27.3.22). The investigation concluded at the end of the inquest on the 28th of April 2023. The cause of death was recorded as being due to 1(a) Hanging and the conclusion of the inquest was that of suicide. The evidence indicated that Mr Shambrook was under the care of the mental health services and that there had been a referral to the Home Treatment Team, however he did not meet their criteria for treatment.

The circumstances of the death are that Mr Shambrook took his own life by hanging [REDACTED] on the 27th of March 2022.

During the course of the inquest the evidence revealed the following matter giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows. The health board (by their own admission through counsel) acknowledge that there is no documented or robust policy in relation to decision making/meeting criteria and thereafter future treatment and care pathways when a patient is referred to the Home Treatment Team

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.