Isobel Stapleton

I am David Regan, Assistant Coroner, for the coroner area of South Wales Central.

A Coronial investigation was commenced on 19th July 2022 into the death of Isobel Lilian Stapleton. The Investigation concluded at the end of the inquest which I conducted on 19th June 2024. The conclusion was that Ms Stapleton died from suicide. The medical cause of death was 1 (a) lncisional Injury to Right Femoral Artery and Vein.

These were recorded as: Isobel Stapleton, aged 32, suffered depression. She was admitted to the Royal Glamorgan hospital as a voluntary inpatient on 18th June 2022 for assessment and was reviewed by a consultant psychiatrist. She was discharged on 24th June 2022, returned to reside with her father and received treatment from the home treatment team.  On Saturday 9th July 2022 Ms Stapleton was at home and appeared to give no cause for concern until her father heard her call from upstairs. He found her on the floor of her bedroom with significant bleeding [REDACTED]. He summoned help and comforted her as she lost consciousness.  Paramedics were deployed at 14.49 and attended at 14.54 but her life could not be saved.  It is likely that her injuries were self inflicted. Ms Stapleton expressed a clear intention to end her life in a hand written note found at the scene. The Inquest focused upon the following: The assessment and management of the risk posed by Ms Stapleton to herself. The information available to medical professionals and information sharing between professionals and agencies. The availability of psychological assessment and treatment resources to the inpatient team at the Royal Glamorgan hospital and the home treatment team covering Merthyr Tydfil. The involvement of Ms Stapleton’s family in discharge planning.

During the course of the inquest the evidence revealed matters 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. For your information the MATTERS OF CONCERN are as follows: {1) Mental health practitioners are not easily able to access all of a patient’s relevant clinical records pending the introduction of a “Once for Wales” solution, for which there is currently no timetable for implementation. Mental health practitioners may not be aware of the existence of all such records, some of which may be in paper. Mental health practitioners in Wales currently have no way easily to access NHS England clinical records. The inpatient hospital team at the Royal Glamorgan Hospital did and does not have access to a clinical psychologist to provide direct assessment and treatment of a patient. {5) The Home treatment team covering Merthyr Tydfil does not have access to a clinical psychologist to provide direct assessment and treatment of a patient. The waiting list for any necessary psychotherapy is months in length.

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