Hospital treatment of suicidal father not 'robust'

The health board said it would learn from the case

Mental health nurses at a hospital failed to recognise a father's suicidal thoughts days before he was found dead, an inquest heard.

Matthew Salisbury was found dead in his car at a disused quarry in May 2019.

A psychiatrist reviewing the case said treatment decisions at Glangwili hospital in Carmarthen had not been "robust". Coroner Paul Bennett recorded a conclusion of suicide

Hywel Dda health board has said it "accepts the inquest findings".

Its Director of Nursing, Quality and Patient Experience, Mandy Rayani, said it "will ensure all learning points and lessons from this case are shared throughout the health board".

The 34-year old from Dolgoed, Crymych in Pembrokeshire had gone to hospital with his wife after threatening to kill himself, but was not admitted despite his wife pleading with staff not to send him home.

The inquest heard she felt they were not being treated seriously.

Nurses said Mr Salisbury told them he promised his wife and children to say alive for 6 months

Independent expert psychologist Professor Kevin Gourney told the inquest Mr Salisbury's case had a "very worrying starting point" given he had both the intent and a plan to kill himself, as well as a family history of depression.

He also told the coroner that mental health nurse Emma Morgan's records from the day of Mr Salisbury's visit to hospital did not describe some of the detail of the case.

"I don't really understand why a more robust course of action wasn't proceeded with," Professor Gourney said.

Mr Salisbury, a father to a two-year old daughter and stepfather to girls aged 11 and seven, was sent for treatment in the community, according to his wife Tara said, because no beds were available.

'No serious mental illness'

Mental health nurse Emma Morgan told the inquest she should not have told the couple there were no beds available, as this would not have affected the decision about his treatment.

She told the coroner that Mr Salisbury's depression did not seem "severe" when they met, and that he had a calm and open manner.

Mental health nurse Leigh Roberts also told the inquest he "did not present with a serious mental illness."

She felt that they developed a "good rapport" and their conversation seemed to have a "therapeutic effect".

Ms Morgan told the inquest Mr Salisbury told the nurses he had "promised" his wife and kids "to stay alive for 6 months."

The nurses then devised a plan for Matthew to go home and be cared for in the community.

Mr Salisbury's wife persuaded him to go to hospital

'Rollercoaster'

Pembrokeshire coroner Paul Bennett said that Mr Salisbury's wife had described a history of mental health problems. Her husband had feared he was schizophrenic and bipolar.

"He became paranoid - his symptoms became worse, he thought he was being followed, and could hear footsteps behind him," she said.

Life with Mr Salisbury was "a rollercoaster - he was either on top of the world or underneath it," Ms Salisbury.

She told the inquest he would suddenly "dip low" and not be able to get out of bed or eat for days at a time.

In 2017, the couple separated temporarily because Mr Salisbury's mental health problems were too disruptive for the children.

At this point, he moved to Coventry to stay with a friend, and his wife told the court he started to suffer from "psychosis" and relied heavily on drugs and alcohol.

She became so worried about him that she brought him back to Wales, where his condition briefly seemed to improve. In the week or two leading up to his death, suicide was "all he seemed to talk about or think about", Ms Salisbury told the inquest.

Once he he had made a plan and said his goodbyes, she persuaded him to go to hospital, she told the inquest.

She had promised her husband: "if they don't help you, then I won't stop you."

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