According to an inquest, a 21-year-old man committed suicide while he was waiting for a counseling appointment.
Twm Bryn, a resident of Chwilog, Gwynedd, had been experiencing "low with his mood deteriorating" ever since he had been the target of a brutal assault months earlier.
He had alerted a mental health nurse to his suicidal thoughts, and she put him on a waiting list for counseling.
Coroner Sarah Riley stated that she would write to the Betsi Cadwaladr health board to express her concern regarding lengthy lists.
In October 2021, Mr. Bryn was discovered hanged close to his house.
At a hearing in Caernarfon Coroner's Court, Ms. Riley came to the conclusion that Mr. Bryn committed suicide.
Coroners may request that steps be taken be taken to prevent further deaths by submitting a report to the health board, which she promised to do.
The lack of support available to those not deemed to be at high risk of suicide is another issue Ms. Riley said her report would highlight in addition to her worries about waiting lists.
The Betsi Cadwaladr Health Board declared that in response to the coroner's concerns, an action plan had been developed.
Mr. Bryn was assaulted in July 2021 and sustained a concussion; according to his mother, this made him occasionally afraid to leave the house.
The health board's target of 28 days was missed when Mr. Bryn's referral for a mental health assessment took 40 days, according to the inquest.
A phone assessment, according to his mother, was insufficient to address his needs at the time.
His family expressed worries about how easily accessible mental health services were in north Wales, highlighting the fact that clients had to make their own referrals.
Tom Regan, the health board's head of nursing for north-west Wales, testified during the hearing on behalf of the organization that at the time, waiting lists for counseling services were longer and staffing shortages were a problem.
Mr. Regan quoted from an internal report into the death that Mr. Bryn was determined to have a "medium" risk of suicide.
According to Mr. Regan, some weekend clinics are now available to deal with the added pressure, and goals are consistently being met.
According to him, the current wait times for counseling are four to six months.
If you or someone you know has been impacted by the problems mentioned in this article, information on the support services is available. the web page for the BBC Action Line.
