Man who killed himself was a known suicide risk
A MAN who killed himself after lighting a fire in his stepfather’s garage had a chronic and ongoing risk of suicide, according to clinicians in charge of his care.
Christopher Jones, who had schizophrenia, paranoia and Asperger’s syndrome, had been staying at the Talygarn unit at County Hospital in Pontypool and Ty Skirrid in Abergavenny since Boxing Day 2018 but was allowed to leave Talygarn by himself on the day of his death.
Mr Jones, 32, was identified through DNA analysis of a toothbrush due to the severity of his injuries as a result of the fire which happened on the morning of July 22, 2019, at Coed Camlas, Pontypool.
On the final day of a six-day inquest into Mr Jones’ death the court heard how clinicians accepted he was at risk of suicide and had been for some considerable time but he was still allowed to leave the unit.
Earlier in the inquest the court heard from Dr Ita Lyons, a consultant psychiatrist in Talygarn who cared for Mr Jones since 2011, who said Mr
Jones’ relationship with suicide was “chronic and ongoing”.
She said Mr Jones had a fixed belief about fire and had believed he could “control it” and he saw suicide as a “reasonable option to sort problems”.
Chief coroner for Gwent Caroline Saunders told the hearing on Tuesday: “Chris’ detention under the Mental Health Act was to reduce his risk of suicide. That was a stated aim of his detention and the number one bullet point in his risk management plan.
“Both diagnoses (schizophrenia and Asperger’s) impacted on Christopher’s mental health and the way he responded to challenges in his life. This would cause distress and could lead to Christopher attempting to take his own life.”
Mr Jones had shown physical signs of wanting to take his own life before. He set fire to a mattress in his flat in Pontypool before being admitted to
Talygarn in December 2018. From that date Mr Jones had been effectively homeless due to an eviction.
The court heard, though, that Talygarn was not an appropriate place for his care. Staff who worked at Talygarn “repeatedly indicated” to the court previously that they had little training in helping patients with Asperger’s, Ms Saunders said.
On January 21, Mr Jones started having unescorted leave from Talygarn because he was showing signs of progression. He had been making so much progress that he was deemed well enough to be transferred to the Ty Skirrid unit in March – with fewer restrictions and which is more focused on patients considered in a rehabilitative phase.
But on June 5, 2019, Mr Jones purchased two batches of paracetamol when on escorted leave with a support worker. After receiving this news staff at Ty Skirrid and Talygarn decided Mr Jones would be immediately transferred back to Talygarn where he would be subject to close supervision. The court heard that staff “felt they had no option” because of concerns the purchase of paracetamol suggested he intended to take his own life.
But Mr Jones was soon back to having up to two hours per day unescorted leave and unlimited escorted leave. It was while he was on unescorted leave on July 22 that Mr Jones took his own life.
On July 15 Mr Jones asked clinicians if he could have further leave from Talygarn.
Ms Saunders reminded the jury hearing the inquest that Mr Jones’ care plan included continued detention within an inpatient setting to manage his needs and risks, that he was assessed by qualified staff prior to any leave, and that staff were to be vigilant regarding access to materials which could aid carbon monoxide poisoning.
The jury unanimously decided on a narrative conclusion, which reads: “Christopher Jones was suffering from Asperger’s syndrome and paranoid schizophrenia on July 22, 2019. Christopher died in a fire which he
started at Coed Camlas, Pontypool. At the time he was on leave from the Talygarn unit at County Hospital in Pontypool where he was detained under section three of the Mental Health Act. Christopher died from suicide.”
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