Less than 24 hours after being admitted to hospital for mental health issues, a 25-year-old Clynderwen man walked in front of a train and was instantly killed.

Robert Jones 'had not been properly assessed' by health staff at St Cadoc’s Hospital, Caerleon, the inquest heard, after police found him ‘confused and covered in mud’ on the A465 near Abergavenny.

When the officers asked him if he had ever had any thoughts about self-harm or suicide, he responded by talking about a  bridge in Haverfordwest. 

Robert Jones was detained under the Mental Health Act and taken to hospital.

But Senior Coroner Caroline Saunders said this was the ‘last and only time’ that anyone had directly asked him about thoughts of suicide or self-harm.

Despite speaking to the police officers about suicide and after attempting to leave the hospital on two separate occasions on Friday, September 27, health staff had placed him on the lowest level of observation.

The following morning, Saturday, September 28, Robert Jones slipped security and escaped through the ward’s communal garden before walking into the path of an incoming train.

Ms Saunders went on to say that Mr Jones had a history of mental health problems which often proved overwhelming.

At an initial hospital assessment he had spoken about hearing voices however this hadn’t been fully documented by staff; similarly, despite police having told the medical staff of their information concerning the bridge, he was not asked about suicidal thoughts during his assessment 

The coroner said that failing to do so was an ‘omission’ in Mr Jones’ care. 

Shortly after the assessment Mr Jones asked for some fresh air and was allowed outside where he tried to open a nearby van.

When asked to stop, he began walking down the driveway.

Staff retrieved him and put him inside a car, but again he managed to get out through a window. 

He was again retrieved and brought back into the hospital.

Mr Jones woke up at around 4.30am on the morning he died, and made numerous phone calls to his mother.

He was seen at 7.30am but during the ward check at 8am he couldn’t be found.

Police were alerted and it was later confirmed that he had been killed by a passenger train travelling from Cardiff to Crewe at around 8.05am.

His cause of death was suicide.

“This was a failure,” concluded Ms Saunders.  “Had he been on 15 minutes observations, his departure could have been avoided.”