Man died on the day he left mental health unit
A CARE coordinator and a psychologist involved with the care of a man who died in a fire in his stepfather’s garage say they were surprised he had been allowed to leave a mental health unit alone prior to his death.
Christopher Jones, who had schizophrenia and paranoia, 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 for a few hours on the day of his death, an inquest at Newport Coroners’ Court heard.
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.
In her statement, Mr Jones’ mother Kathie Jones said at first she heard a loud cracking sound. “I looked up and saw the garage was on fire and my partner at the time immediately ran out,” she said.
She said she heard someone “screaming in pain” and had thought it was a dog walker.
“I still believed it was a passing dog walker that had been hurt,” she said. “Then I looked at my phone and saw I had missed calls from Talygarn, and they told me Christopher had not returned from leave.”
Ms Jones said it “came as a shock” to her that her son had been allowed to leave the unit, and that once she had realised he wasn’t at the unit, she had believed it was him in the garage.
Station officer for South Wales Fire and Rescue Anthony Jackson told the court how he found Mr Jones’ body in the garage.
Mr Jackson, who was in charge of investigating the cause of the fire, said the investigations concluded that the fire was caused by “ignitable liquid that had been deliberately ignited”.
He believed the presence of a lighter in the garage was key to the findings. In the years leading to his death the court heard Mr Jones had often spoken to staff at Talygarn about suicide by fire.
Pathologist Dr Richard Jones’ report advised that Mr Jones had died as a result of exposure to fire and fire effects.
He found no evidence of alcohol or non-prescribed drugs in Mr Jones’ system at the time of his death.
Mr Jones was transferred to Ty Skirrid in Abergavenny in March, but then was sent back to Talygarn in June after staff realised he had bought medication in excess over two separate visits to a shop actions which concerned them.
Consultant psychiatrist for Talygarn Dr Ita Lyons said staff felt the news of the purchases had “seriously increased” his risk of suicide.
The court heard from community care coordinator Karen Addyman, who said she knew Mr Jones well, but was rarely contacted by either the Talygarn unit or Ty Skirrid – where Mr Jones was also cared for between March and June 2019 – for advice on his treatment.
She told the court: “Christopher had a diagnosis of autism and he sometimes did not appear to understand that he had a diagnosis of schizophrenia. He often had thought he was being attacked and he wanted to move away, but Christopher did not understand that these issues would come with him.”
Ms Addyman said she was directly involved with Mr Jones’ care until December 12, 2018, and there “didn’t appear anything untoward”, but just after that he set fire to a mattress in his flat in Pontypool before being admitted to Talygarn.
Ms Addyman told the court that from that date Mr Jones had been effectively homeless because the landlord had evicted him for the mattress fire.
While Mr Jones was detained at the Talygarn unit under the Mental Health Act, staff had decided he could occasionally leave the unit for therapeutic reasons – at that time while under supervision.
Ms Addyman, who did not appear to have attended any ward rounds where Mr Jones’ care was discussed between December 2018 and March 2019, says she is now expected to have more involvement with patients in ward settings, as are her colleagues working in community care, as a result of Mr Jones’ passing.
On behalf of Mr Jones’ family, Marcus Coates-Walker asked Ms Addyman whether to her knowledge Mr Jones had had suicidal thoughts. Ms Addyman replied: “Yes. You could tell his mental health was deteriorating but he did not specifically say to me he had plans to kill himself.
“I was surprised he had gone on unescorted leave, because previously it had all been escorted to my understanding.”
In a statement, psychologist Gemma O’Brien said she would have expected staff at the units to do a fire risk course with Mr Jones, and regular risk assessments.
She said: “Considering his risks, I am really surprised Christopher had leave.”
She added she had concerns he was allowed to purchase over-thecounter medication while supervised, and worried about what he could have done while not on escorted leave.
Consultant psychiatrist Dr Lyons said: “He had a chronic belief that he wanted to die which was difficult if not impossible to change. He had voiced that to me on many occasions and he had attempted it many times.”
The inquest continues.