The grief-stricken parents of a young man found dead at home have spoken of how things may have been different for him had an error not delayed him receiving medication he had long requested to be prescribed.
The go-ahead for Connor Richard Davies, 21, to have medication to treat his ADHD was given on April 18, 2019, months after he had told medics his condition had worsened without it.
However, tragically three days earlier, on April 15, 2019, Connor was discovered dead in his home in Swansea, Wales Online reports.
A three-day inquest held into his death saw assistant coroner, Aled Gruffydd, return a suicide conclusion.
The inquest heard how a year had gone where Connor was not on ADHD medication and on October 9, 2018, he expressed his desire to be put back on it.
His request was referred to Dr Reddy, but an administrative error meant it did not reach him.
The request was repeated in February, 2019, but by the time the go-ahead was given for the medication to be restarted on April 18, 2019, it was too late for Connor.
Mr Gruffydd said at the inquest how, whilst Mr Davies had been responsible for the prescription initially relapsing, he had requested to restart the medication six months before he passed away.
He added: "Had that breakdown in communication not occurred in October, and Connor received his ADHD medication, it is my view that this would have had an impact on his impulsive behaviour and he would have fallen back into the pattern that he was in when he was taking it regularly.
"It is my conclusion that it was not depression that was causing his suicidal impulsive behaviour – it was ADHD. As such, I find the failure to restart the ADHD medication was a failure that played a factor in Connor's death.
"An administrative error was responsible for the referral not making it to Dr Reddy. There is an acknowledgement that Dr Reddy was effectively running the service on his own with a long waiting list.
"I'm satisfied measures have now been put in place to stop further patients falling through the net. I'm satisfied measures put in place will reduce further deaths."
At the conclusion of the inquest, Mr Davies's parents, mum Michelle Lewis and dad Richard Davies, paid tribute to their son, and spoke of how they felt things could have been different had matters been addressed earlier.
They said: "He was a bubbly character and always laughing and smiling. He had lots of mates and had a really big funeral. He loved his daughter and really embraced fatherhood. He also loved his nieces and nephews.
"He had a big passion for rugby and played for Vardre RFC on the wing. He loved football too. He was a very good mechanic and would do other things like carpet fitting and labouring. He loved his motorbikes as well - he would strip a bike down and rebuild it.
"He'll always be remembered for his sense of humour and his smile. We'd like to thank the coroner for coming to his conclusions. Connor was failed, it was down to the ADHD tablets. If he had them, I think it would have been different. We hope the changes being put in place will stop this happening to anyone else."
Mr Davies had been diagnosed with ADHD at the age of 17 and had once been prescribed stimulant ADHD medication Concerta XL by Dr Duvvoor Reddy, a psychiatrist who was the only practitioner able to deal with the condition in the Swansea area.
Mr Davies found it helped his condition but he began to experience side-effects of a loss of appetite and chest pains. The medication was therefore changed to a non-stimulant medication and he was discharged back to the community mental health team.
Having been diagnosed with mental health issues and depression he was also prescribed sertraline with his dosage upped in incremental stages from 50mg to 150mg – something his family feared was not appropriate for him without a proper assessment given the drug being linked with an increased risk of suicidal thoughts in some people.
Addressing Mr Davies's parents' concerns about the dosage of sertraline he was prescribed, Mr Gruffydd said: "Although the risk is there to be recognised I am unable to conclude that the prescription of sertraline was inappropriate."
The coroner also addressed the decision taken not to admit him into hospital for treatment – something that Mr Davies's parents had repeatedly pleaded for after their son took a number of overdoses. He had been assessed several times at Cefn Coed Hospital but was released back into the care of his parents each time.
Mr Gruffydd said: "In this case, although the family wanted his admission to hospital, it was felt that whilst there was a pattern of behaviour developing it was felt that all treatment where possible should be given in the community. I can't conclude the decision not to admit him was wrong."
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