### Inquest Reveals Gaps in Mental Health Care after Tragic Death of Brynamman Father
An inquest has found that David Hornsby, a 34-year-old father of three from Brynamman, lost his life to suicide following repeated cancellations of his mental health support appointments. The hearing, held at Swansea’s Guildhall, shed light on the struggles Mr Hornsby endured as he sought help, only to face systemic challenges within the local health service.
Mr Hornsby’s mental health battles were well documented. Diagnosed with depression and anxiety linked to long-term substance misuse, his case was managed by the Swansea Bay University Health Board. Despite his clear need and repeated pleas for assistance, his family relayed that support was often unavailable when most needed.
Testimony at the inquest included statements from consultant psychiatrist Dr. Muthukkumaar Gnanavel and health board manager David West. Both acknowledged the immense pressures staff faced, particularly during the Covid-19 pandemic when staffing shortages and unprecedented demand put the system under strain. Dr. Gnanavel conceded that lessons have been learned following Mr Hornsby’s tragic death, and outlined steps being taken to bolster support for vulnerable patients.
The inquest heard that Mr Hornsby’s mother, Sally Hornsby, was deeply concerned about her son’s wellbeing in the months preceding his death. She recounted how a promising young man gradually deteriorated as addiction and poor mental health took hold, especially during bouts of unemployment. Attempts to obtain help were met with cancelled appointments and inconsistent care.
Crucially, on 26 August 2022, Mr Hornsby was found dead at home by his partner. The evening before, he was described by a friend as behaving erratically and out of character. Although he left no note, a text message suggested he intended to end his life. It emerged that he had previously made several suicide attempts and, according to his family, had even engineered his own arrest in a desperate bid to access support. Appointment cancellations seemingly exacerbated his sense of isolation.
Further investigation revealed a pattern of infrequent review appointments, with Mr Hornsby at times not being seen for as long as ten months—far longer than the health board’s stated targets. When queried regarding the repeated cancellations, Dr. Gnanavel pointed to ongoing doctor vacancies and immense operational difficulties during the height of the pandemic. Ms Hornsby, however, pressed for clearer accountability, questioning how obvious signs of suffering could have been missed.
In response, the health board has since implemented a range of changes. David West confirmed that more robust risk assessments are now standard, more comprehensive sharing of patient information between departments has been introduced, and patients notified of cancellations are now signposted towards alternative support options. Importantly, the board has also pledged not to cancel clinical appointments within six weeks of the scheduled date to reduce disruption to care.
The issue of continuity of care also came to the fore, as the inquest heard that Mr Hornsby saw a different junior doctor at each visit. This lack of consistency, noted Coroner Colin Phillips, can hinder effective management, particularly for at-risk individuals.
Ultimately, the coroner’s verdict was one of suicide. The case highlights ongoing challenges for mental health services in Wales and across the UK, particularly the extremely damaging impact that cancelled appointments and inconsistent support can have on those seeking help.
The health board insists that lessons are being heeded. Yet, Mr Hornsby’s family remain acutely aware of the gaps which failed their loved one, calling for greater urgency in mental health reform.
If you or anyone you know is struggling with mental health issues, support is available around the clock from the Samaritans on 116 123 or by emailing jo@samaritans.org. Further resources, including online chat and self-help tools, can be accessed via the Samaritans website.