Isaac Ingle-Gillis

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

On 12/2/2025 an investigation was opened touching upon the death of Isaac Arlan Ingle-Gillis The investigation concluded at the end of the inquest on 18/7/2025 The conclusion of the inquest was recorded as Suicide The medical cause of death was: 1a) [REDACTED] Toxicity

Isaac Arlan Ingle-Gillis was suffering from depression. He died on 9/2/2025 at the Ty Hotel in Magor from the effects of an intentional overdose of [REDACTED].

The MATTERS OF CONCERN are as follows: – Isaac Arlan Ingle-Gillis presented to his GP on 20/12/2024 having made preparatory attempts to obtain [REDACTED] to end his life and had attempted to stab himself through the heart. The GP referred Isaac to the Crisis Resolution and Home Treatment Team (CRHTT), who duly assessed Isaac later that day. The assessment included information obtained from a telephone conversation with the GP prior to the assessment. Isaac was discharged following the assessment without follow up. Thereafter Isaac engaged with his GP but took his own life on 9/2/2025, in the circumstances described in Box 4. During the inquest I heard evidence that the CRHTT do not have access to the GP records. I could not determine on balance of probabilities that access to additional information recorded by the GP in their consultation with Isaac on 9/2/2025 would have changed the assessment made by the CRHTT on this occasion. However, I am concerned that in future this information (or lack of it) may be vital.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. I understand that Aneurin Bevan University Health Board, through the Deputy Medical Director, have a role in overseeing GP Surgeries and liaison between the inpatient and GP based teams. Kindly inform me whether there are plans to allow secondary care practitioners access to GP records.