A “kind, warm-hearted” man with mental health issues died after he was hit by a moving train, an inquest has been told.
Robert Jones, 25, died after he was struck by a passenger train near Newport on September 28, 2019.
On Wednesday Newport Coroners Court heard Mr Jones, from Clynderwen, Pembrokeshire, was killed at around 8.05am on the morning of September 28, 2019 after he walked onto train tracks near St Cadoc’s Hospital, where he had been admitted the day before due to concerns over his mental health.
A statement read out on behalf of Mr Jones' mother Sharon Harris said her son was a "kind, warm-hearted man" with whom she had a "special relationship." She said he had had a "happy childhood" and had made friends in school but was diagnosed with dyslexia at a young age.
"He excelled at artwork and had a real talent for art," she added, saying her son had a "unique style" and had even sold some artworks in Swansea. He studied art and design and "was always making you laugh with his funny accents."
Ms Harris said her son had a number of interests including the environment and politics and that he was a "kind, warm-hearted man who will be missed forever." She had spoken to Mr Jones over the phone and by text in the days prior to his death. The day before he died he rang her and said 'I love you mum'. She said she had been due to pick him up from the hospital on September 28 and that he had texted her that morning asking how she was. She texted him on the morning he died asking 'where are you.'
Ms Harris said Mr Jones' family had been "absolutely crushed" by his death as her son "was just finding his niche in life." She said he was "open minded and knowledgeable about life" and that she had "learned so much from him.
"He was my friend as well as my only child and I miss him so much."
Witness PC Elliot Morgan from Gwent Police told the court Mr Jones had been found walking on the A465 near Abergavenny on Friday, September 27, miles from his home in west Wales, the day before he died.
He said he had been on duty with a fellow officer PC Jenkins at around 12pm that day when they received a report of a man in a field near Abergavenny who was reported to be "very confused, scared for his life and covered with mud." They were then told there was a man walking along the A465 dual carriageway in the area, where they eventually located Mr Jones walking.
He said Mr Jones was "confused" and told them he was there for a funeral, adding that Mr Jones was "covered with mud" and was unable to tell officers what had happened to him. He had with him his phone, a notebook of drawings and a number of train tickets showing journeys from Haverfordwest to Newport and Shrewsbury. When asked by police why he was in Abergavenny he could not recall having gone there but said he had gotten off the train as he said people had been "trying to chase him and kill him."
He said Mr Jones spoke about a "bridge in Haverfordwest" and that he believed Mr Jones was "paranoid" that people were "after him" and was suffering from mental health issues.
After speaking with a mental health practitioner at Gwent Police PC Morgan and his colleague brought Mr Jones to St Cadoc's Hospital in Newport under section 136 of the Mental Health Act. He said he formed the view Mr Jones was having suicidal thoughts due to his comments about a bridge and the fact he was walking along a busy dual carriageway.
The court also heard on Wednesday from a number of witnesses involved in assessing Mr Jones in St Cadoc's Hospital the day before he died.
Eleanor Sparshott, deputy ward manager at the Bellevue ward at St Cadoc's Hospital, told the court she spoke to Mr Jones' mother before he was admitted and that she told her he had been suffering from mental health issues for the past five years and had been living near her house in a caravan. She also spoke to his Hywel Dda University Health Board who said Mr Jones had had a social worker but had been discharged in June 2019.
Although police had included Mr Jones' comments about a bridge in their part of a section 136 report being completed in St Cadoc's, Ms Sparshott said she could not remember being told specifically about them and did not record them in her own notes. She said however that Mr Jones spoke about "hearing voices in his head."
Questioned by Miss Gowman, representing Mr Jones' family, on why she had not taken account of the police references to a bridge in her notes, Ms Sparshott said it had been an "oversight" on her part. After Mr Jones was assessed by mental health staff and psychiatrists it was decided that he would be informally admitted for treatment and that he would be transferred back to his local area, where he was more familiar, to be cared for the following day.
After his assessment at around 5.20pm on Friday the court heard Mr Jones asked for some "fresh air" and was allowed outside of the hospital building. He then tried to open a nearby van and, when asked by staff to stop, began walking down the driveway of the hospital. Staff from the hospital went to retrieve Mr Jones in a nearby laneway and after succeeding in bringing him into a car, he later got out of the car via a window before once again being brought in and returned to the section 136 suite of the hospital.
When asked why he had attempted to leave after accepting informal admission to hospital, Ms Sparshott said Mr Jones said he was "trying to make his way home." Questioned on why Mr Jones was not further assessed after he had left, she said his behaviour was "calm and compliant" when he returned and that she did "not consider him at risk of absconsion."
Ms Sparshott confirmed that she did not have access to patient information held on other systems, as Mr Jones was not from the Aneurin Bevan Health Board area. She conceded it "would be helpful" in order to treat out-of-area patients - of which Mr Jones was her first - if this had been possible.
Julie Heal, an approved mental health professional and team manager at Monmouthshire County Council's social work team, also took part in assessing Mr Jones on the afternoon he was brought to St Cadoc's.
She recalled that while Mr Jones had no difficulty answering questions that he seemed "somewhat confused" and that she felt some of what he said was "confabulation" and "contradictory." She said he told her he was doing an accountancy course but also said he hadn't enrolled yet. She asked him if he had been in touch with his mother and he initially said he had, but after looking through his phone said he in fact hadn't.
Ms Heal also said she was unable to access some of Mr Jones' records before carrying out his assessment as he was not from the local area. Asked why he was not detained under section two of the Mental Health Act, she said she "always offers the least restrictive option" for patients. Questioned by Miss Zeb, asking questions on behalf of Aneurin Bevan University Health Board, Ms Heal confirmed Mr Jones had consented to informal admission without complaint and that she believed he had the capacity to do so.
Dr Deepak Megeri, also part of the panel who carried out Mr Jones' assessment, was a locum consultant psychiatrist at Aneurin Bevan University Health Board at the time, though he no longer works there.
He said his view during that assessment was that Mr Jones was "low in mood" but that he "denied hearing any voices." When asked by senior coroner Caroline Saunders why he might have given contradicting information about this, Dr Megeri said his responses "might have been different with different professionals."
Dr Megeri also said he took the information about Mr Jones referring to bridge "literally" and therefore took him to be "high risk." When asked if by this he meant Mr Jones was at risk of self harm he said: "My take was that he was at high risk of being vulnerable and making impulsive decisions." He said he did not recall asking Mr Jones any direct questions about whether he was having suicidal thoughts during the assessment.
"He had put himself in a high risk position [walking out on the road] which was more convincing for me that he was high risk," he said.
When Miss Gowman put to him that he would have been "ideally placed" to be involved in discussions over Mr Jones' level of observation by staff after his assessment, Dr Megeri said it was not "routine practice" for him to make recommendations on how often patients should be observed after this point, saying this was decided by nursing staff and the on-call consultant depending on the patient's behaviour at that time.
A statement read out on behalf of John Wilson from British Transport Police said that a passenger train travelling from Cardiff to Crew at around 8.05am on Saturday, September 28, 2019 had struck a man after he emerged from undergrowth near the train tracks. Dr James Harrison, a consultant pathologist, later confirmed Mr Jones had died from "injuries consistent with being struck by a train."
The inquest, which is expected to last three days, continues.
For confidential support the Samaritans can be contacted for free around the clock 365 days a year on 116 123.
