Deeside train death man: 'Unsatisfactory delay' in care
A mental health patient faced an "unsatisfactory delay" in seeing specialists before he ran in front of a high-speed train, a coroner has said.
John Gittins will write to Betsi Cadwaladr University Health Board outlining concerns after an inquest into the June 2015 death of Christopher Jones, 26, from Deeside.
A narrative conclusion was given after Mr Jones died from multiple injuries.
The health board said a "serious incident review" was carried out.
Mr Jones had been suffering mental health problems before he ran into the path of a fast-moving train near Chemistry Lane, Pentre, Deeside, on 15 June 2015.
During the two-day inquest, in Ruthin, Jane Marks said she tried to stress to professionals caring for her son that he would harm or kill himself.
He had been discharged from hospital in January 2015 and had weekly sessions with the community mental health team.
The team's Gareth Davies said Mr Jones seemed to have an "insight into his problems", with a "marked decline" in paranoid behaviour before his death.
He said his death came "out of the blue".
However, counsellor Julie Scott said she had noticed a "sharp decline" with him describing suicidal thoughts.
She arranged an emergency appointment with GP Dr Lenka Zigova, who told the inquest she did not think there was an immediate risk and prescribed him anti-depressants.
However, he died days before a consultant psychiatrist was due to carry out an emergency review of his condition.
Coroner for North Wales (East and central), Mr Gittins recorded a narrative conclusion, in which he referred to an "unsatisfactory delay" in the formulation of a care plan and risk assessment.
He also pointed to the "inadequate escalation of concerns at a time of significant decline in his mental health".
Mr Gittins said to try and prevent future deaths he would issue a letter to the health board expressing concern about consultants' reviews being held on an annual basis.
"In Christopher's case, it might have been the summer of 2016, 18 months after his discharge," he said.
A health board spokesman said it had carried out a serious incident review and will "take on board" the coroner's recommendations.