Image copyright Google Image caption The inquest was held at Ruthin County Hall

A man killed himself after a mental health referral was downgraded from "urgent" to "routine" by a health board, an inquest has heard.

David Albert Jones, 67, from Llanbedr-Dyffryn-Clwyd, Denbighshire, died in November just days after a referral to Betsi Cadwaladr health board (BCUHB).

Assistant coroner Joanne Lees, said she was concerned by the communication error and would write to BCUHB.

The health board said it accepted the coroner's recommendations.

Mr Jones, a farm worker, had been treated for severe anxiety and depression since 2014 and had been referred to the community mental health team by his GP, Dr Timothy Buckley, after a visit in November 2018.

He told Dr Buckley he had no thoughts of suicide or self-harm, but an urgent referral was made to the community health team after a "deterioration in his mental state".

Psychiatric nurse Sue Shaw told the inquest in Ruthin that Mr Jones seemed better when she saw him the same day, but that he needed to be seen "as soon as possible".

'Not communicated'

Ms Shaw submitted a report to the multi-disciplinary team (MDT) which met five days later on 21 November - and although she said she had recommended the case be expedited, there was no record of such an assessment, and the MDT agreed to treat it as a routine case.

She told the coroner she could not explain how the case came to be downgraded from "to be expedited" to "routine".

Recording a conclusion of suicide, Ms Lees said: "It seems to me that the recommendation from Mrs Shaw that it be expedited was not communicated."

But she added: "It is entirely possible that he might have been given an earlier appointment but I cannot make a link between that and his death."

She said she would not be issuing a Regulation 28 report to prevent future deaths but would ask BCHUB to review its decision-making process and how recommendations were communicated to the MDT.

BCHUB said: "We extend our sincere condolences to David's family at this very sad time.

"We accept the recommendations made by the coroner and are committed to improving communication between the different teams in the health board."