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pandora charms Recording a narrative verdict, Neath Port Talbot coroner Philip Rogers said he was “absolutely satisfied” the system did not work at the time.Mr Rogers was told that Mrs Thorne had a history of psychiatric illness, which started a number of years before her death, when she discovered that her daughter was using Class A drugs.As a result pandora bracelets, Mrs Thorne and her husband Paul started looking after their granddaughter, and the inquest was told that she found it stressful and difficult.On 25 March, Mr Thorne called the out of hours GP service, because Mrs Thorne told him she needed help.A doctor visited their home and assessed her to be “suicidal” and referred her to hospital.She went to Ward F of Neath Port Talbot Hospital a specialist psychiatric ward for adult patients.But an assessment by staff nurse Lindsay Martin and the senior doctor on call on the ward Mahibur Rahman found she was at “low to some” risk of self harm.Dr Rahman discharged her with a three point action plan and referred Mrs Thorne to the out of hours psychiatric service, to be monitored over the weekend.He also referred her to a day hospital, for extra support, and to her consultant psychiatrist for a possible change of medication.Mrs Thorne had been taking the anti depressant, Amitriptyline for several months.But the coroner said the evidence proved “no effective steps” were taken to deal with her case after the 25 March.Mrs Thorne was found dead at her home five days later.”Other actions have also been taken to improve our service, including better communication systems between senior clinical staff and the teams looking after patients,” it added.In a statement through his solicitors Mr Thorne said: “Our whole family have been devastated by the loss of Avril.”I sincerely hope that the NHS does not let this happen to any other family.”Had Avril received the support she needed then her tragic death would have been avoided. The BBC is not responsible for the content of external sites. Read more.This page is best viewed in an up to date web browser with style sheets (CSS) enabled pandora charms.

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