THE inquest into the death of a man who struggled with his mental health for most of his life is to become a catalyst for improving services to other people facing similar challenges and their families in North Wales.

Peter Welsby, 44, died at home in Maesgwyn, Kinmel Bay, on Saturday, August 5, 2022.

The cause of death was pneumonia but, due to Mr Welsby's history of alcohol misuse and mental health issues, it was decided that an inquest into his death was needed.

That inquest resumed and was concluded by Senior Coroner for North Wales East and Central John Gittins at County Hall, Ruthin, on Thursday (February 15).

Mr Welsby was the youngest of six children originally from the Culcheth area of Warrington.

When he was young the family moved to Kinmel Bay after his mother was advised to move close to the sea for her health.

At the age of 15, due in part to his mother's death and an incident in which he was stabbed, he began experiencing mental health problems that, the inquest heard, he self-medicated with alcohol.

The inquest was attended by three of Peter's siblings, including his sister, retired nurse Jane Collinson.

They had concerns about their brother's treatment for his mental health in the years prior to his death.

Some of these concerns were allayed during the inquest, such as Mrs Collinson's feeling that her brother would die if he wasn't given detox and rehab treatment as a matter of urgency.

"He was so ill."

"I could see him fading away before my eyes," she told the inquest.

"I thought the only thing that might have saved his life was detox and rehab, and that would have to be quite fast, and that was just not forthcoming."

Later she expressed the frustration her family felt.

"What do you do?

"Do you actually have to go and kill someone to get mental health treatment and support?

"That is what this county has become."

"I had looked after Peter since I was 18.

"My question is how do you get help? That is what I've been asking for 25 f****ing years."

The coroner said this was a common experience for families, perhaps more so for those without a medical background.

However, during the inquest, Mrs Collinson said she had taken some comfort from learning that her brother's liver disease, resulting from his alcohol use, would likely not have proved fatal if not for his bout of pneumonia.

Another concern, which was sympathised with by Mr Gittins, was a feeling that her brother's alcohol issues were prioritised over his mental health.

Three representatives of Betsi Cadwalader University Health Board's Substance Misuse Services (SMS) - Head of Nursing Sean Gallagher, Clinical Operational Manager Lisa Wright, and Interim Director of Mental Health and Learning Disabilities Iain Wilkie - appeared as witnesses.

They were able to reassure Mrs Collinson that Peter was being prioritised for mental health treatment in the months before he died.

However, they admitted there had been a slight delay as, due to living on the border between counties, he was referred to Conwy rather than Denbighshire.

What the witnesses did accept though was that families of patients should be involved more in decisions, support and treatment.

Mrs Wright invited Mrs Collinson to speak about the family's experiences at training sessions with a view of improving services.

She said: "This is what we need to learn from."

Joking about Mrs Collinson swearing in his court, Mr Gittins said that as "the mouthy one" in the family she might be best placed to work with SMS in North Wales to make a real difference.

He said that the system isn't perfect and that, due to pressures on services, those working at the frontline where often doing so with "one hand tied behind their back".

But he agreed "families need to be kept in the loop".

Mr Wilkie said it was a "fantastic opportunity to learn" and the inquest drew to a close with the family and health professionals exchanging contact details.

Ending the inquest, Mr Gittins recorded a conclusion of an alcohol-related death.