A “missed opportunity” in the care of a nursing student who committed suicide

A coroner said there was a “missed opportunity” in the care of a 26-year-old nursing student who took her own life, but there was insufficient evidence to prove this contributed to her death. Bronwen Morgan, from Cardiff, died in 2020 after consuming a toxic substance she bought online.

On the final day of the inquest at Pontypridd Coroner’s Court it was found that Miss Morgan, who suffered from an emotionally unstable personality disorder, was under the care of staff at the Cardiff and Vale University Psychiatric Board. She was dissatisfied with the care they received and felt she was not being listened to before her death. The qualified primary school teacher, who was studying to be a mental health nurse, tried to commit suicide several times in the months before her death.

Miss Morgan, who lived in Roath, emailed the health board’s complaints department on August 23, four days before her death, saying not enough was being done for her, which she had repeatedly put herself and her family were at risk and needed more help. intervention. She said it was too late for her. Dr Laurence Mynors-Wallis, a Dorset psychologist who was not involved in Ms. Morgan, told the inquest that the email should have been passed on to her customer service team.

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Coroner Graham Hughes said it was a “missed opportunity” but also noted that Dr Minors-Wallis was not convinced that different handling of the emails would have prevented Miss Minors-Wallis’ death. Morgan. “The threshold of evidence was not met for me to reach a positive conclusion that this missed opportunity contributed to Bronwen’s death,” the coroner said.

Hughes also appealed the medical team’s decision not to refer Morgan to a specialist inpatient unit. The team believed that, like Ms. Morgan was still receiving dialectical behavior therapy (DBT) in the community, “her risk of self-harm had not become unmanageable”. The coroner did not rule against the decision, but said it should have been discussed with Miss Morgan and her family.

“In my opinion, it was a miscommunication,” Hughes said. But he highlighted Dr Mynors-Wallis’ view that better communication “probably would have changed the outcome, but it is not likely”. The coroner said it “probably could not have been the cause of Bronwen’s death”. He added that Dr Minors-Wallis believes the health package is “substantial”, although there are “areas for learning”.

Recording a finding of suicide, the coroner noted that in the days prior to her death, Miss’s mood had changed. Morgan had “improved markedly,” which “often” happens in suicide cases. He said the degree of planning, previous self-harm and the investigation and acquisition of the toxic substance supported Miss’s intention. Morgan from taking his own life.

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