When Dorian Phillips lost his mother following her short illness, his life slowly fell to pieces.
“They were very close. In fact, he adored her,” his sister Tanya Fenn told today’s inquest into his death.
“He became reclusive, it was evident that he was closing down to everyone and even during her funeral he turned away from people. From then on, he was on a slippery slope.”
On January 8, 2020, Dorian Phillips - described by his GP as a chronic alcoholic - made an emergency call to the police informing them that he had taken an overdose and had also slit his wrists.
Officers immediately conveyed him to Withybush Hospital where Mr Philips met the Crisis team. However after a 45-minute conversation, Mr Phillips was allowed to leave.
At 10.30am the following morning, a fisherman who had known Mr Phillips for many years discovered him floating face down in the sea just below the quay wall at Lower Town, Fishguard.
A lifeboat was called to retrieve him from the water and he was identified as Dorian Phillips. He was pronounced dead at the scene.
At today’s inquest at County Hall, Haverfordwest, members of the Crisis team confirmed that during their time with Mr Phillips the day before his death, he didn’t display any suicidal intentions, despite attempting to cut his wrists and taking an overdose the same day.
“He didn’t appear to be depressed, he was very articulate and he didn’t give us any reason for concern,” said Mr Phillip Collins, a former bank nurse for the Crisis team who attended to Mr Phillips on January 8.
This was echoed by registered nurse Helen Morgan.
“He didn’t present as someone with serious mental health issues but a man who was frustrated about living next to his neighbour who irritated him a lot,” she said.
“He was very positive about moving forward and it sounded as if the situation was reactionary. Dorian was adamant he wasn’t going back to Fishguard that day, but would go to the council and seek alternative accommodation.”
When asked why his attempts to take his life with an overdose and by slitting his wrists hadn’t prompted concern with the Crisis team, Ms Morgan said this is often the way in which a person can release their frustrations and anxiety.
“He told us he was relieved the overdose hadn’t worked and he was not intending to take another one. And this [an attempted suicide] can sometimes be enough to give a person relief of what they were experiencing at the time.”
Acting senior coroner Paul Bennett also heard from Pembrokeshire County Council’s housing advice team who provided Dorian Phillips with advice concerning his housing issues.
The officer confirmed that as a result of his dissatisfaction with his neighbour in West Street, Fishguard, Mr Phillips had been placed in the ‘silver band’ placement as a result of his medical issue. This meant that he wasn’t placed in high priority.
“Even though this wasn’t ideal, when Dorian left the interview that day he was a lot more positive than when he arrived,” said the officer.
Meanwhile a report by pathologist Dr John Murphy concluded that Mr Phillips’ death was the result of drowning. Post mortem evidence showed that at the time of his death, he had 380mcg of alcohol in 100ml of blood as well as traces of therpeutic medication, including cannabis.
After listening to the evidence, Emeritus professor Kevin Gourney, a chartered practitioner psychologist at the Institute of Psychiatry in London said he had heard nothing during the inquest that caused him concern regarding the way in which Dorian Phillips had been cared for by the Crisis practitioners.
“They were very experienced and took time and trouble to connect as far as they could,” he said.
Professor Gourney also concluded that there had been ‘a pivotal point’ in Mr Phillips’ mental health following the death of his mother.
Following a 90-minute adjournment, acting senior coroner Paul Bennett said he was settled there hadn't been a deliberate attempt by Dorian Phillips to end his own life.
"What he did was the result of an act which, unintentionally, took a wrong turn," he said. "He found himself in the water having consumed a large quantity of alcohol. This wasn't suicide but misadventure."
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