Susan Evans inquest: 'Risks not communicated' before hospital death
A woman who had previously overdosed, took her own life after the risk she posed to herself was not communicated, a coroner said.
Susan Evans, 75, was found dead at Withybush General Hospital in Haverfordwest in 2014.
In a narrative conclusion assistant coroner Gareth Lewis said precautions were not taken by nurses and consultants.
Dr Warren Lloyd, of Hywel Dda health board, said it offered its "sincere condolences" to the family.
The inquest at Milford Haven Town Hall heard how Mrs Evans was treated in Bro Cerwyn mental health unit at Haverfordwest before being admitted to a cardiac ward at Withybush.
Hospital notes suggested she was "extremely low" and suffered from depression.
On 17 November nurses noticed Mrs Evans was missing from her bed before realising she had locked herself in the ward bathroom.
However, the agency nurse responsible for Mrs Evans on the night shift, Janet Sicath, said she was not made aware Mrs Evans had tried to kill herself in the past.
Ms Sicath said she did not "usually get all the details from nurses in a handover".
In a narrative conclusion, Mr Lewis said: "The deceased took her own life, in circumstances where the risk that she might do so was not communicated and precautions were not taken to prevent her doing so."
Specifically, he said Mrs Evans was transferred from a psychiatric ward to a medical ward "without a sufficiently comprehensive explanation of the risk that she might take her own life".
An independent report written in March 2016 by Professor Bob Peckitt as part of a police investigation found "trust policy in respect of patient transfer and sharing of risk assessments was not followed".
Professor Peckitt's report concluded he was concerned for patient safety and he recommended an urgent independent review be carried out by Hywel Dda health board "without delay".
Speaking after the inquest, Susan Evans' son Bill said the family was disappointed that remedial measures have still not been implemented.
Dr Lloyd said: "We accept the findings of the coroner and as a health board we have implemented changes following an internal investigation.
"We will also be working with Mrs Evans' family on further changes in the future."