An inquest held last week in Milford Haven heard how a number of mental health care failings led to the death of a Pembroke man.

The body of 28-year-old Lance John Kenneth Osborn, of Holyland Drive, a former pupil of Tenby Junior School and Greenhill School, was recovered by the police marine unit on May 31, on the shoreline between Milford Haven and Neyland, after his blue Vauxhall Corsa had been found in a car park near to the Cleddau Bridge, following a ‘missing persons’ search by the police, fire, coastguard and lifeboat services.

An initial inquest into his death was adjourned back in September at the request of the family, after they made the coroner aware of complaints they had made towards the health board in the lead up to the hearing.

At the inquest into his death on Friday (February 16), a spokesperson for Hywel Dda University Health Board said the authority fully accepted there were failings in the care of Mr. Osborn.

“I think there were a number of things identified in the report which the health board acknowledges,” Janet Griffiths told the hearing via conference call.

“An action plan has been drawn up to address these failings and to ensure change is necessary change is carried out to ensure that this does not happen in the future,” she explained.

Pembrokeshire coroner Mark Layton recorded a narrative conclusion, stating the cause of death as drowning.

Mr. Layton stated that Mr. Osborn had entered the Cleddau Estuary, on May 31, with the intention of taking his own life.

“At the time of death, he was in the care of mental health services, and there were failings in the care he received,” explained Mr. Layton, who went onto say that screening and allocation discussions about Mr. Osborn should have been adequately documented in official records, and staffing issues which led to a delay in referral should have been passed on to management.

“These issues are identified as shortcomings that will now be addressed by the health board in relation to the care of future patients,” he continued.

“I very much hope the health board and the standards they are setting are maintained for patients in the future,” added Mr. Layton.