An urgent referral by a GP on behalf of a patient suffering from severe anxiety was downgraded to “routine”, with the result that no immediate appointment with the mental health team was fixed.

Before he was seen, however, 67-year-old David Albert Jones, killed himself, leaving a note for his family apologising for his actions.

Dr Timothy Buckley, who had expected him to be contacted within 48 hours, said he was “devastated” to learn of his death.

At an inquest in Ruthin Joanne Lees, assistant coroner for North Wales East and Central, said she was concerned at the apparent error in communication and would be writing to the Betsi Cadwaladr University Health Board to highlight the issue.

But she added: “It is entirely possible that he might have been given an earlier appointment but I cannot make a link between that and his death.”

Mr Jones, a farm worker, of Maes Derwen, Llanbedr DC, near Ruthin, first suffered from severe depression in 2014 and said he didn’t think he could carry on living. He told Dr Buckley, however, that he had no thoughts of suicide or self-harm.

In November, 2018, he again saw Dr Buckley and although he said he had no faith in GPs’ ability to solve his anxiety problem he again said he had no thoughts of suicide.

Dr Buckley prescribed anti-depressants and Mr Jones seemed much calmer.

“I felt there seemed to be a deterioration in his mental state,” said the doctor in a statement read at the hearing.

He made an urgent referral to the community mental health team, but psychiatric nurse Sue Shaw said that when she spoke to Mr Jones the same day he seemed better.

“There was no mention of him being suicidal,” she said. “My view was that he did not need to be seen on the 16th but as soon as possible.”

Mrs Shaw submitted a report to the multi-disciplinary team (MDT) which met on November 21 – five days later – and although she said she had recommended that the case be expedited there was no record of such an assessment, and the MDT agreed to treat it as a routine case.

Mr Jones called the surgery on November 20 asking whether he could have an appointment at the local hospital, but was found hanging at his home on the 26th.

Mrs Shaw told the coroner she could not explain how the case came to be downgraded from “to be expedited” to “ routine”.

Recording a conclusion of suicide, Mrs Lees commented: “It seems to me that the recommendation from Mrs Shaw that it be expedited was not communicated.”

She said she would not be issuing a Regulation 28 report to prevent future deaths but would ask the Health Board to review its decision-making process and how recommendations were communicated to the MDT.