A Eglwyswrw man took his own life just days after visiting a hospital with depression, an inquest has heard.

The body of Matthew Ian Phillip Salisbury, who was 34, was found in a car near a disused quarry near Llangynog on May 28, 2019.

He died from carbon monoxide poisoning days after an attempt by his family to admit him to hospital for depression.

At an inquest held at Llanelli Town Hall on March 14, acting coroner for Pembrokeshire and Carmarthenshire Paul Bennett said that due to discrepancies in evidence it was difficult to conclude if enough was done to help Mr Salisbury.

Mr Salisbury's wife Tara told how, on the night they tried to get an admission to hospital, her husband had revealed his intention to take his own life.

Mrs Salisbury asked her husband to accompany her to hospital one final time.

The couple arrived at Glangwili Hospital on May 26, 2019 – two days before Mr Salisbury’s body was found in a car with a note saying 'don't look inside call the police'.

At the hospital a mental health assessment ensued, however the nurses assessing Mr Salisbury deemed his depression not serious enough to warrant him being admitted.

Mrs Salisbury said that when her husband realised what was happening, his answers to the assessment became flippant so he could get out of hospital as quick as possible.

Of his final hours at home Mrs Salisbury said: “We sat and talked and he went back drinking again.

“Eventually I had to go to bed. He left at some point then appeared back again in the early morning.

“I came downstairs to find him in the lounge acting erratically."

Mr Salisbury left the house and did not return.

Mrs Salisbury said she had done all she could to keep him alive, including paying off his drug debts.

“My last hope was to take him to A&E. I was distraught that this was the last chance I had to help him and it did not work.”

At the inquest, Professor Kevin Gourney, emeritus professor at the Institute of Psychiatry, Psychology and Neuroscience, Kings College London, said there were a triad of concerning symptoms that warranted admission: suicidal ideation, planning and intent.

Giving evidence, mental health nurses Emma Morgan and Tracey Roberts, said Mr Salisbury did not exhibit severe symptoms of depression at the time of the assessment, which made them conclude he did not need hospital admission or further assessment from a clinician. 

Mrs Morgan said: “Mr Salisbury was making eye contact, he was able to give a good account of himself, he’d shown a willingness to co-operate with health professionals and seemed to have some sort of future planning.”

There were noted discrepancies in the evidence given by both parties such as Mrs Salisbury’s view that Mr Salisbury had become disengaged to the assessment when he discovered he was being sent home. Mrs Morgan said this did not correspond with her memory at all.

In his conclusion Mr Bennett said: “There were some evidential contradictions between evidence given by Mrs Salisbury and nurse Morgan which I find difficult to resolve.

“While I understand the difficulties in taking a note of everything that happens in assessments such as these, it makes it problematic for me to determine whether the treatment plan was appropriate so I need to be guided by expert opinion.”

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