Health workers missed opportunities to help a man who died after being allowed to leave hospital, an inquest heard. Liam Griffith Williams, 40, of Llanfairpwll, who had a history of mental health issues and was being treated at the Hergest Unit in Ysbyty Gwynedd, Bangor, was discovered in a storage lock-up.
Mr Williams was taken to Hergest for treatment but died on October 8 last year, an inquest in Caernarfon heard last week. Sarah Riley, assistant coroner for North-West Wales, was informed that Mr Williams had sent a message to his wife on October 4 indicating he would harm himself.
Message not passed to doctor
She alerted a call handler at the Hergest Unit in Ysbyty Gwynedd and the information was recorded in the ward log; however, it was not passed on to a doctor, the inquest was told. Mr Williams was later permitted leave from the Hergest Unit, but the doctor stated that had he been aware of the message about self-harm, he would have discussed it further with Mr Williams. The doctor added that approval to leave would have been based on Mr Williams' "response".
The coroner found he granted four-hour leave to Mr Williams on October 4, 2025, to be taken the following day. On October 5, a registered mental health nurse reported that Mr Williams was dressed and "looking forward" to seeing his family.
Death and findings
She had no concerns, so Mr Williams was duly allowed to take his unescorted leave. However, Mr Williams was later found in a storage lock-up in Star near Gaerwen, the inquest heard. He was brought back to Ysbyty Gwynedd for treatment but died there three days later on October 8 last year.
Ms Riley found he died from a hypoxic brain injury due to hanging, adding that there had been "missed opportunities" to help Mr Williams. Ms Riley said Betsi Cadwaladr University Health Board failed to share information about the comments Mr Williams made to his wife, and the message was "not available" to the doctor.
Giving a narrative verdict, she said: "Mr Williams' death occurred in the context of a number of missed opportunities by the health board to review and escalate" his case.
Health board response
Teresa Owen, executive director of allied health professionals and health science, acknowledged the findings and recommendations. She stated: "On behalf of the health board I would like to extend our sincere condolences to the family of Liam for their sad loss.
"We accept the coroner's findings and recommendations, and recognise the importance of learning from this case.
"Since these events, we have received and strengthened arrangements relating to risk assessment, communication between clinical teams, care planning and clinical oversight.
"We have also taken steps to improve the involvement of families and carers in care planning and ensure their concerns are appropriately considered. We will continue to monitor the improvements made to ensure they are embedded in practice."
