A CORONER has raised concerns after a local 21-year-old dad was found dead by his father only three weeks after being discharged from the crisis mental health team. 

In the early hours of March 27, 2019, Kieran Crimmins’ body was discovered close to his family’s house in Milford Haven.

Mr. Crimmins had been discharged from the Hywel Dda Crisis team three weeks prior, on March 5, despite displaying “maladaptive coping mechanisms” and repeatedly threatening to take his own life. 

Paul Bennett, a senior coroner for Pembrokeshire and Carmarthenshire, questioned whether it was wise to complete a multi-agency referral form (MARF) over the phone, whether there were “inconsistencies” in the manual diary system the Hywel Dda mental health team used to keep records, and whether there were “no effective means” of monitoring Kieran’s mental health after his release. 

Following a four-day inquest into the events leading to Kieran’s death, Mr. Bennett will now decide whether to make a Regulation 28 Prevention of Future Deaths Report (PFD), which would force Hywel Dda health board to rectify any potential weaknesses

Since he was a young child, Kieran had been under the supervision of the Hywel Dda Health Board’s mental health services and had frequently sought help at Withybush hospital.

Speaking after the inquest had concluded, his family said: “He was funny, entertaining, and an empathetic young man. He would brighten any room and would help anyone who asked, wanting nothing in return.”

However, beneath Kieran’s cheerful exterior was “a deeply troubled soul.” The inquiry learned that during his brief life, he experienced serious trauma, including the deaths of numerous dear friends and family members.

According to psychological testimony given at the inquest, his inadequate coping skills and pre-existing special educational needs made it difficult for him to handle the severe swings in his mental health. 

His family were his “protective” measures when things got tough.

Acting for Kieran’s family, Ben Blakemore said: “Kieran and his family did not feel listened to or recognised when begging for the intervention that it is clear, and hindsight shows, he desperately needed.” 

He was engaged with the Dyfed Drugs and Alcohol Service, and an inquiry into a drug-related driving offence was pending at the time of his death (DDAS).

Several witnesses, including those responsible for Kieran’s care and treatment for the Hywel Dda health board, testified in front of Mr. Bennett.

A crisis team practitioner with the Hywel Dda University Health Board pushed hard for Kieran to be admitted to the hospital on February 27, 2019, one month before he passed away, after he tried to end his life by overdosing on drugs.  

Dr David Sheppard interviewed Kieran at the time, who kept referring to suicidal thoughts and made several references to taking his own life.

Dr. Sheppard requested that a hospital bed be found for him that night in a conversation with Hywel Dda duty manager Donna Phillips, but Mrs. Phillips informed him that there were no beds available. 

Following that, Mr. Crimmins was offered the choice of staying at Withybush A&E or going back home with his parents. He made the decision to go home.

He returned to hospital the following day and was assured the Crisis team would visit him on a daily basis for the next two weeks. On March 1, a team member paid him a visit, and on March 2, he got a call from them, which is when the MARF referral happened. 

Kieran saw no one on March 3 or March 4. Despite going missing twice during that time and being located by police on one of those times, it was decided on March 5 that he should be released from their service.

Despite communication with DDAS and Hywel Dda’s integrated psychological therapies programme, Mr. Blakemore claimed that Kieran was “essentially left to his own devices.” Mr Bennett added: “I have some concerns around the decision making process.”

Three weeks later, on March 26, Kieran sent his former girlfriend and a friend of his each a message that raised concerns. When his parents learned that their son had left the house, they called the police and started looking for him.

Just after midnight, his father discovered his body. Despite paramedics’ best efforts to revive him with CPR and a defibrillator they had brought to the scene, Kieran was pronounced dead upon being taken to Withybush.

His sister, Katie Crimmins, who was only 18 when she learned that her older brother Kieran had passed away, claimed that hospital workers failed to provide any assistance to the family, leaving them to cope with the unbearable loss on their own.

Kieran, who had only recently become a father and was an avid fisherman and DJ, had long battled mental health problems including depression and PTSD.

His family claimed he struggled to receive the professional help he required. The transition of his care from child and adolescent mental health services (CAMHS) to adult mental health services allegedly ran into more issues.

As a result of the cell phone interaction, Mr. Bennett came to the conclusion that Kieran died by suicide as there was “sufficient evidence of Kieran’s intent to end his life and of him taking the steps to do so”. He added that he died of asphyxiation due to self-suspension. 

He added: “A decision was taken not to refer to the Community Mental Health Team for ongoing monitoring of his mental health and care co-ordination following his discharge from the Crisis and Home Treatment Team on March 5 due to the fact that he was receiving support from the Dyfed Drug and Alcohol Service and the Independent Psychological Therapy Service.”

After the inquest was over, Mr. Blakemore, who represented his family, released a statement saying: “Mental Health Service provision in Pembrokeshire and the wider Hywel Dda Health Board is long overdue a review so as to ensure that individuals do not believe that suicide is the only option they have. Kieran’s family has pursued change through this inquest forum, and hope it will follow.

“Kieran’s death must not be allowed to be just another statistic. Change is needed to avoid more people with vulnerabilities and thoughts such as those Kieran suffered from losing their life, and more families going through this hollow hell.”

Mr Blakemore urged Mr Bennett to consider making a Regulation 28 PFD report. Luke Garrett, representing Hywel Dda health board, made a submission that the matters raised by the coroner “will be considered” and that the use of the diary system would be “reviewed and strengthened” and the health board would “endeavour to provide information on MARFs on a face-to-face basis”.

Mr Bennett agreed to “give the matter due consideration” and will issue his decision within the next few days. 

He closed proceedings by expressing his condolences to Kieran’s family and commending them for the “way they conducted themselves” throughout. 

He added: “I’m sure there’s not much I can really add to the expressions of sympathy already shown.”

Kieran’s family also thanked the support they’d received from 2Wish and Get the Boys a Lift, and stated that without it, they would have been left “without any support at all at what has been the most horrific time of their lives”.