Mental health fears not shared with psychiatrist - inquest

Lowri Miller's social worker raised fears that she had spoken about ending her own life

A psychiatrist involved in a decision to discharge a woman who died a day after leaving a mental health unit was not told about her state of mind, an inquest has heard.

Lowri Miller, 32, from Beddau, Rhondda Cynon Taf, was found dead at a friend's house in February 2020.

A social worker raised concerns about her discharge from the unit at Royal Glamorgan Hospital the previous day.

Pontypridd Coroner's Court heard procedures had since been changed.

Consultant psychiatrist Dr Kishore Kale told the hearing he was not told that Lowri had threatened to kill herself.

She had told her social worker and care coordinator Emma Roberts she "did not want to be alive anymore" and had a plan to end her life.

Dr Kale said he was not told about Ms Roberts' concern that Lowri had "never seemed so hopeless" nor that Ms Roberts did not feel comfortable about Lowri being discharged.

"I would have expected that information to be passed to me," he told the hearing.

Lowri Miller had a history of mental ill-health

Ms Roberts told the inquest she spoke to Lowri privately after they both attended a 45-minute discharge meeting involving Dr Kale.

Ms Roberts said she was so worried about what was said, she went to find Dr Kale but was told he was in a meeting.

She said she spoke instead to a member of the nursing team, but Dr Kale told the hearing he "wasn't made aware" of her concerns.

Dr Kale, who was the unit's clinical director, said he had not met Lowri prior to the discharge meeting and was covering for a colleague who was on leave.

He said Lowri was a voluntary patient who had come to the unit after taking an overdose and did not qualify for detention under the Mental Health Act or meet the criteria to be detained against her will.

Pontypridd Coroner's Court was told the mental health unit at Rhondda Cynon Taf made changes following Lowri's death

Lowri's mother, Susan Miller, said she got texts from Lowri saying the meeting had not gone well and she was unhappy about being discharged.

She said her daughter's behaviour had changed significantly, talking for the first time about how she was feeling and wanting to stay in hospital.

"She had never previously asked to stay in hospital, usually she couldn't get out of those places quick enough," Ms Miller said.

That evening Lowri sent a number of text and social media messages to her mother and sister saying she had asked for help but felt she had been turned away.

She told them: "Nobody cares."

She told her sister, Rhiannon, she could not go on living and wanted to be "at peace".

Rhiannon said she told her sister that she and her family loved her and cared for her.

Pathologist Dr Jason Shannon, who carried out the post-mortem examination, said he believed Lowri had died of sudden arrhythmic death which, on the balance of probabilities, was caused by a pharmacological reaction to her prescribed medication and another medication she had taken.

Ms Roberts said procedures had now changed and care coordinators could escalate concerns over a discharge decision to senior nursing staff.

The inquest continues.