Robert Smith

I am Andrew Morse H M Coroner , for the coroner area of South Wales Central.

On 30 October 2023 I commenced an investigation into the death of Robert Maxwell SMITH . The investigation concluded at the end of the inquest 07/05/2025 . The conclusion of the inquest was Suicide. 1a Pressure On Neck, Consistent With Hanging 1b 1c II

CIRCUMSTANCES OF THE DEATH: These were recorded as follows Robert Maxwell Smith died on 26 th October 2023 at [REDACTED], Cardiff. Mr Smith died by hanging [REDACTED]. It is more likely than not that he intended the consequences of his action to result in his own death. Mr Smith had recent contact and intervention from mental health services and was known to be at risk of suicide due to a deterioration in his mental health presentation over the preceding weeks. Mental heath services did not inform Mr Smith’s wife of the extent of his suicidal ideations. Mr Smith had indicated that he would inform his wife of his raised suicidal ideations but did not do so. On balance, it cannot be said that if such information had been provided, Mr Smith’s suicide would have been prevented. Conclusion: Suicide

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. The MATTERS OF CONCERN are as follows.

1. The guidance provided to clinicians and nursing staff within the mental health  services as to when information and sharing and information gathering was to be  undertaken with, and from, family members and how such decisions are to be  recorded on the standard forms lacked clarity, particularly as regards the distinction  between information sharing and information gathering. Such guidance being of  relevance when a patient has given consent for information sharing and gathering to take place and when, and in what circumstances, such steps would be taken.
2. The information leaflet provided to patients lacked sufficient detail of the approach  taken by mental health services on the issue of information sharing and information gathering so that patients could readily understand the difference between the two  and understand when the need for information sharing and/or gathering could arise and what steps would be taken by mental health services.

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.