A PREVENTION of Future Deaths (PFD) report has been issued after an inquest found that a man who took his life in Abergele was not transferred to a community mental health team in Conwy.

Richard Geraint Griffiths was found dead in the town on March 26 at the age of 53.

At a full inquest into his death, held in Ruthin on September 14, Kate Robertson, assistant coroner for North Wales East and Central, recorded a conclusion of suicide.


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Mr Griffiths was under the care of the South Gwynedd Community Mental Health Team prior to moving to Conwy to live with his mother in October 2022.

For reasons unknown, a transfer of care did not occur for Mr Griffiths following his relocation.

Ms Robertson has since sent a PFD report to Betsi Cadwaladr University Health Board (BCUHB), raising the following matters:

  • BCUHB’s own investigation into Mr Griffiths’ death was, she said, “deficient” in that it did not contain “pertinent points” concerning how or why the transfer of care did not take place.
  • BCUHB’s Transfer of Care document at the time did not include any detail or process as to how the transfer should occur. Its amended policy has still not been finalised.
  • Notes for mental health patients are paper-based rather than electronic; Ms Robertson said there has been “considerable delay” in changing this, and “still no anticipated timescale” for this to occur.

BCUHB is duty-bound to respond to the report by November 9, containing details of action taken or proposed to be taken, and setting out the timetable for action.

Otherwise, the health board must explain why no action is proposed.

For support, contact the Samaritans by calling 116 123.