"SEVERAL opportunities" were missed to highlight the problems of a schizophrenic man and improve his care in the months leading up to his death, a coroner has ruled.

At the end of a five-day hearing an open conclusion was recorded on 32-year-old James Lockett, who was found dead in his flat in Mostyn Road, Colwyn Bay, on December 6, 2016.

Several empty packets of his anti-psychotic tablets were found nearby but it proved impossible to ascertain the cause of his death, partly because his body was partly decomposed.

On November 20 James allegedly assaulted two police officers who had gone to arrest him for breaching his bail, and he was Tasered and beaten on the head with a baton.

His parents George and Deborah Lockett believed that the trauma of the incident, for which he was kept in custody for two days, played a part in his death.

James was under the care of the community mental health team and the inquest in Ruthin heard of the systems in place for monitoring his compliance with his medication.

Recording her conclusion, Joanne Lees, assistant coroner for North Wales East and Central, said she found that the arrangements by North Wales Police for the arrest on November 20 were acceptable as the officers had no reason to think it was anything other than a routine arrest, James having been compliant on previous occasions.

But Mrs Lees highlighted various issues where communication between the police, mental health team and social services had been poor, with the police having failed to notify the health workers that James had been arrested in July for an alleged assault and subsequently for the assault on the officers.

“On four occasions between July and December social services had information that he had been in the court system but that was not shared with the CMHT,” she said.

It was impossible to tell, however, whether the missed opportunities contributed to James’ death.

A further hearing will be held next month at which the coroner will consider whether to issue a Regulation 28 report to prevent future deaths, but she highlighted issues which were concerning her at this stage.

Those concerns include the monitoring of James’ compliance with his medication and poor record keeping, and the lack of information sought by the mental health professionals to enable them to make informed decisions.

In particular, she voiced concern about James’ care co-ordinator Andrew Salter, a witness at the inquest, who was new to the job and admitted that some of the care between November 20 and December 6 had been “inadequate”.

Mr Salter was taken on by the Betsi Cadwaladr University Health Board through an agency as a locum and Mrs Lees said she would be contacting his professional body.

After hearing the conclusion Anna Morris, the Locketts’ barrister, said they were anxious that no other family should have to go through the same experience and still had concerns about several issues.

She said that although the police put markers on the files of people with mental health problems they were not specific enough.

“They are too general to assist in any real assessment and should flag up someone with a serious mental health illness such as schizophrenia,” she said.