Coroner 'not satisfied' Lowri Miller meant to kill herself

Lowri Miller was found dead at a friend's house the day after she was discharged

Doctors were unaware a woman had a plan to end her life when she was discharged from a mental health unit, a coroner has found.

Lowri Miller, 32, from Beddau, Rhondda Cynon Taf, was found dead the day after being discharged on February 7 2020.

Recording a narrative conclusion, coroner Graeme Hughes said Lowri died from a "sudden cardiac event" after taking a mixture of drugs.

But he could "never have been satisfied" she meant to kill herself.

He said Lowri had "flirted with the concept and risk of death but on each occasion had pulled back from it".

The inquest heard that Lowri's social worker and family had raised concerns about the decision to discharge her from the unit.

• Social worker raised mental health fears - inquest

• Mental health fears not shared, inquest hears

Lowri 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.

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

Psychiatrist Dr Vineet Kuntal said that Lowri had been assessed as having "no acute risk of suicide" but did have a "chronic risk of self harm".

Cwm Taf Morgannwg University health board told the inquest that the discharge procedure had now been changed.

In a statement, Lowri mother Sue Miller said the family were "enormously saddened" to hear of the "failings" during Lowri's final admission to hospital.

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

Dr Kuntal said that decisions regarding discharge were a collective decision made by a group of clinicians led by consultant Dr Kale.

He said he did not recall anyone in the meeting expressing disagreement.

Lowri had withdrawn consent for her mother to be given any information about her discharge.

The coroner heard that she left hospital with just one day's medication, despite a plan to provide her with enough for four days and an offer from her mother to assist in administering it to her.

Ms Miller described Lowri as a "bubbly, happy girl who made friends everywhere she went".

She added: "The social worker was uncomfortable with the decision to discharge Lowri because she felt that Lowri would overdose on discharge.

"This information did not reach clinical staff and Lowri was discharged the next day."