“Our son died three days before receiving the medicine that could have saved his life, after an administrative error”

The grieving parents of a young man found dead at home have explained how things could have been different for him if an administrative error had not delayed him receiving the medication he had long requested. The green light for Connor Richard Davies to resume medication to treat his ADHD was given on April 18, 2019, months after he told doctors his condition had worsened without it.

But, tragically, three days earlier, on April 15, 2019, the 21-year-old was found hanged at his home on Gellionnen Road in Clydach, Swansea. A three-day inquest into his death at the city’s Guildhall saw Deputy Coroner Aled Gruffydd issue a finding of suicide.

The inquest heard how a year had passed while the Arfryn School alumnus was off medication for ADHD and on October 9, 2018 he expressed his desire to be back on it. His request was forwarded to Dr. Reddy, but an administrative error meant that it did not reach him. The request was repeated in February 2019, but by the time the green light was given for the drug to be restarted on April 18, 2019, it was too late for Connor. You can get more Swansea news and other story updates by subscribing to our newsletters here.

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Mr Gruffydd told the inquest how, when Mr Davies was responsible for the initial relapse on the prescription, he asked to restart the drug six months before his death, adding: ‘If this breakdown in communication does not s hadn’t been produced in October, and Connor was given his ADHD medication, I’m of the opinion that this would have had an impact on his impulsive behavior and that he would have fallen back into the pattern he was in when he took it regularly.

“I conclude that it was not depression that was at the root of his suicidal impulsive behavior – it was ADHD. As such, I find the failure to restart ADHD medication to be a failure that played a part in Connor’s death. An administrative error was responsible for the referral to Dr. Reddy. It is known that Dr. Reddy effectively ran the service on his own with a long waiting list. I am satisfied that measures have now been put in place to prevent further patients from slipping through the net. I am confident that the measures put in place will reduce the number of further deaths.” You can read more stories about Clydach here.

You can recap the first day of the hearing by clicking here, the second day of the investigation by clicking here and the third day by clicking here.



Connor pictured with his brothers, Steven and Shane


Connor’s friends and brothers carrying a memorial kit honoring him. From left to right: Luke, Keiran, Callum, Shane and Steven

At the end of the inquest, Mr Davies’ parents, mum Michelle Lewis and dad Richard Davies, paid tribute to their son and explained how things could have been different if the issues had been dealt with sooner. They said: “He was a bubbly character and always laughing and smiling. He had lots of buddies and had a really big funeral. He loved his daughter and really embraced fatherhood. He loved his nieces too. and his nephews.

“He had a great passion for rugby and played for Vardre RFC on the wing. He also loved football. He was a very good mechanic and he did other things like laying mats and manning He also loved his motorcycles – he would strip a bike down and rebuild it.

“He will always be remembered for his sense of humor and his smile. We would like to thank the coroner for reaching his conclusions. Connor failed, it was because of the ADHD tablets. If he had I think it would have been different. Hopefully the changes put in place will prevent this from happening to anyone else.



Connor Davies died suddenly after suffering from mental health issues


Connor (left) with his friend Kieran

Mr Davies had been diagnosed with ADHD at the age of 17 and had previously been prescribed ADHD stimulant drug Concerta XL by Dr Duvvoor Reddy, a psychiatrist who was the only practitioner able to treat the disease in the Swansea region. Mr Davies found it helped his condition, but he began to experience the side effects of loss of appetite and chest pain. The medication was therefore changed to non-stimulant medication and he was referred to the community mental health team.

Diagnosed with mental health issues and depression, he was also prescribed sertraline with a dose increased in stages from 50mg to 150mg – which his family feared might not be right for him without proper assessment given that the drug was linked to an increased risk of suicide. thoughts in some people.

Responding to concerns from Mr Davies’ parents about the dosage of sertraline he has been prescribed, Mr Gruffydd said: “Although the risk is there to be recognized, I am not in a position to conclude that the prescription of sertraline was inappropriate.”

The coroner also referred to the decision taken not to admit him to hospital for treatment – something Mr Davies’ parents had repeatedly requested after their son took a number of overdoses. He had been assessed several times at the Cefn Coed hospital, but each time he had been entrusted to the care of his parents.

Mr Gruffydd said: “In this case, although the family wanted him admitted to hospital, it was felt that even if behavior did develop, it was felt that all treatment, where possible, should be administered in the community. I cannot conclude the decision not to admit it was a mistake.”

For confidential assistance, the Samaritans can be reached free of charge 24 hours a day, 365 days a year, on 116 123.

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