Blaze man took his own life – inquest
AMAN 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, Pontypool, and Ty Skirrid, Abergavenny, since Boxing Day 2018 but was allowed to leave Talygarn by himself on the day he died.
Mr Jones, 32, was identified through DNA analysis of a toothbrush due to his injuries from the fire on July 22, 2019, at Coed Camlas, Pontypool.
On the final day of a six-day inquest, the court heard that clinicians accepted he was at risk of suicide and had been for some 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 had cared for Mr Jones since 2011, who said Mr Jones’ relationship with suicide was “chronic and ongoing”.
Chief coroner for Gwent Caroline
Saunders told the hearing: “Chris’ detention under the Mental Health Act was to reduce his risk of suicide. That was a stated aim of his detention.
“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. 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 progress. He made so much progress he was deemed well enough to be transferred to Ty Skirrid in March – with fewer restrictions.
But on June 5, 2019, Mr Jones bought paracetamol when on escorted leave. After receiving this news staff at Ty Skirrid and Talygarn decided Mr Jones would be immediately transferred back to Talygarn for close supervision. The court heard staff “felt they had no option” because the paracetamol purchase 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. While on unescorted leave on July 22, Mr Jones took his own life.
Prior to his death Mr Jones was made aware he might soon be moving to Pwllmawr mental health unit, which he was aware had more restrictions than he had been used to. The court heard that a doctor in charge of Mr Jones’ care at the time was not supportive of his move to the unit.
On July 15 Mr Jones asked if he could have further leave from Talygarn. Dr Lyons admitted it was a
“difficult time” in Mr Jones’ life because she could not give him a definitive answer on leave or when or if he would be going to Pwllmawr.
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.
Sarah Cadman, of Aneurin Bevan University Health Board, told the inquest that investigating officers found that notes needed to be better updated in assessment prior to patients being allowed to take leave.
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 the Mental Health Act. Christopher died from suicide.”
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