A 21-year-old man who struggled to cope with what psychiatrists referred to as a ‘maladaptive coping mechanism’ and who threatened to take his own life on repeated occasions, was ultimately discharged from the Crisis mental health team.

Twenty-one days later Kieran Crimmins was found dead near his family home in Blackbridge, Milford Haven.

This week Pembrokeshire Coroner Paul Bennett conducted a four-day inquest into the events leading up to Mr Crimmins’ death.

On February 27, 2019, Mr David Sheppard, who is a crisis team practitioner with the Hywel Dda University Health Board, made strong representations for Mr Crimmins to be admitted to hospital after he attempted to take his life with a drug overdose.  Throughout an interview with Mr Sheppard, the deceased kept referring to suicidal thoughts and made several references to hanging.

Mr Sheppard spoke to Hywel Dda duty manager Donna Phillips and requested that a hospital bed be found for him that night, however Mrs Phillips told him that no beds were available.

During her cross examination, solicitor Mr Ben Blakeman who represents Kieran Crimmins’ family, questioned why a bed couldn’t have been found for Mr Crimmins further down the M4 corridor or with an alternative Health Board.

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“We always try to keep the patients local,” replied Donna Phillips. “The patient is already upset and we don’t want them to be told that we’ve found a bed but don’t know when the transport will be arriving. We prefer to keep the person local in A&E until a bed is available for them locally the following morning.”

Mr Crimmins was subsequently given the option of either staying in Withybush A&E or returning home with his parents. Because the A&E room he was told to wait in was ‘highly inappropriate’, he decided to go home.

The following morning Mr Crimmins returned to Withybush where he was seen by Dr Maria Atkins who concluded that he didn’t require hospital admission. Mr Crimmins was assured that the Crisis team would visit him on a daily basis for the next two weeks.

He was visited by a team member on March 1, he received a phone call from them on March 2 and on March 3 and March 4 he saw nobody. On March 5 a registered health care nurse who had never previously met Mr Crimmins spent an hour with him, after which she concluded that he should be discharged from their service.

On March 26 Kieran's parents realised that their son had left home in a distressed state and alterted the police.

Soon after midnight Keiran’s father, Mr Jonathan Crimmins, found his son’s body near the Blackbridge estuary. Despite efforts to revive him with CPR and a defibrillator which was brought to the scene by paramedics, Kieran Crimmins was pronounced dead upon being taken to Withybush. Withybush pathologist Dr John Murphy confirmed that the cause of death was asphyxiation.

The inquest will continue on Monday when Pembrokeshire Coroner Mr Paul Bennett is expected to deliver his verdict.

Where to get mental health support

Here are some websites that can help: 

www.mind.org.uk 

www.samaritans.org

Why do newspapers cover inquests and how do they work?