A young woman was found dead at home after medics decided she was not an emergency case. Cerys Walsh, devastated by the loss of her friend and employer, had emailed South Wales Police telling them where they could find her moments before she took her own life.
GP referral and mental health assessment
She had been seen by her GP days before who referred her as an urgent case to the community health team the next day, her inquest heard. Ms Walsh saw her GP on February 5, 2024, and the community mental health team the next day. They assessed her and signed her off on February 6, and she was found dead on March 12 by officers from South Wales Police at her mother's house in Cardiff.
At the opening of the inquest in March, counsel for the young woman's family, Harrison Lewis, said it was their case that Ms Walsh should have been referred to the community mental health team as an emergency, not an urgent case, when she saw her GP at Rumney Primary Care Centre in Cardiff to ask for help.
GP's decision and background
After seeing Ms Walsh, accompanied by her mother Susan Walsh, on February 5, 2024, her GP Victoria Cole concluded she would be safe overnight with her mother before seeing the mental health team the following day, the resumed hearing on July 21 heard. The practice doctors were aware of her autism diagnosis and history of acute anxiety and that she had twice previously tried to overdose aged 13 and 16.
They were also aware that she had been under child and adolescent mental health services (CAMHS), but that when she reached 18 she had declined re-assessment as an adult. In the five-year gap she had not engaged with adult mental health services, but just before her death Ms Walsh's mental health deteriorated following the sudden loss of her friend and employer, the well-known Cardiff canine specialist Caroline Cowan.
Mental health team assessment
Ms Walsh had spoken of feeling that she had no friends, had stopped walking her dog, was sleeping badly and was wondering what to do. The young woman had expressed suicidal thoughts but told the GP and mental health team she had no intention of acting on them. It was felt she was safe at home with her mother who kept her prescription medication locked up.
When the mental health team saw her on February 6 they discussed with Ms Walsh steps that she might take to ease her anxiety and negative thoughts. These included looking into volunteer dog walking and seeking careers advice. At that meeting the young woman also said she wanted to write her own 'safety' plan at home, rather than with the mental health team, and this was deemed appropriate, especially given her autism diagnosis.
Coroner's findings
As coroner Caroline Morgan read out details leading to Ms Walsh's death, her grieving mother Susan Walsh, who attended the hearing, became upset and had to leave the court. She agreed the hearing could go on without her. The hearing was told that after the mental health team assessment both Ms Walsh and her GP should have received a letter outlining what was diagnosed and agreed, but that letter was delayed until February 31, well outside Cardiff and Vale Health Board's 21-day time limit for it to have been sent, the inquest heard.
Ms Morgan said the delay was 'unfortunate' but not the cause of Ms Walsh's death. But she did order the health board to write to her within seven days saying what steps it had been taken to ensure such delays don't happen again. There was also 'insufficient evidence to suggest mental health services would have been aware of a risk to her life', said the coroner.
She found there had been no systems failure or breach of care as clinical judgements in Ms Walsh's case had been recorded. Neither had the GP's actions been a cause of her death, the coroner found. The GP was aware there were powers to detain patients deemed at risk but she had not felt she had to use them when she saw Ms Walsh on February 5, 2024.
'I could not find any aspect of Dr Cole's actions that could be said to be causative of Cerys' death,' Ms Morgan told the hearing.
Although the mental health team who saw the 24-year-old on February 6, 2024, had not sought her CAMHS notes from seven years previously, the coroner added that she did not find this impaired their assessment of her state at the time they saw her.
'Cerys was accompanied by her mother at the assessment. Cerys communicated she could not see a future after her friend died and she had thought about overdosing, but denied having medications she could use,' Ms Morgan said.
'She was compliant with her prescription medications and her mother stored them. By the end of the nearly hour-long assessment the mental health nurses felt there was no immediate risk to her life. I did not find there is evidence that the assessment or outcome was inappropriate nor causative of Cerys' death.'
Reaching a conclusion of suicide, the coroner expressed her condolences to Cerys's mother and family.
