A CORONER is to send a report to the Aneurin Bevan University Health Board highlighting serious concerns following the tragic death of a grandmother.

Georgina Lewis, from Pontypool, died in 2013 aged 57, “as a result of her own, unassisted act”, just days after being discharged from a mental health unit, an inquest heard.

She had previously experienced mental health issues and had suffered depression and anxiety problems following a diagnosis of breast cancer in 2012.

An inquest at Newport Coroner’s Court on Thursday, December 8, heard she had been admitted to the Talygarn Unit at Pontypool County Hospital after taking an overdose of medication and being found “in a distraught state” in Newport on Wednesday, September 18, 2013.

But she was discharged on Monday, September 23, despite reportedly saying she did not want to go home.

Five days later on Friday, September 27, she left the home of the friend she was staying with, saying she was going to clean her own flat, and was not seen again.

Her body was found in the Pontnewydd area on Monday, September 30.

Senior Gwent coroner David Bowen said he believed there had been “a worrying breakdown in communication between the unit and Mrs Lewis’ family”.

“In fact her family were not involved in the decision to discharge her at all,” he said.

“No action plan was put in place and no report was sent to her GP.

“There was no psychiatric help in place.”

He added: “I can’t help feeling if these shortcomings had not occurred this inquest may not have been necessary.”

Recording a narrative verdict Mr Bowen said: “Her death was the result of her own, unassisted act, having until recently been discharged from a psychiatric unit.”

He will also put together at Prevent Further Deaths (PFD) report, which will be sent to the Aneurin Bevan University Health Board.

In a statement issued by Mrs Lewis’ son John Paul Lewis, daughters Samantha Lewis Butcher and Michelle Rose Smith, sons-in-law Rhys Owain Butcher and Richard Smith and sister-in-law Sarah Lewis said the family had been “utterly devastated” by her death. Georgina meant the world to us,” they said. “She was a wonderful mum, daughter, sister, auntie and grandmother.

“Georgina died after recent contact with mental health services, having been discharged from hospital without appropriate support and against our wishes as her family.

“We are grateful the failures in her care have been identified at this inquest today.”

A health board spokesman said: “Our thoughts remain with the family and friends of Georgina Lewis.

“The health board has conducted a thorough Serious Incident Investigation into the case and we have already taken corrective actions and steps to address the issues raised through an action plan. The actions taken by the health board were positively recognised by the coroner.We also await the PFD report and will actively respond to this report when received.”