Man dies in mental health hospital after staff failings

The family of a man who died in his bed at a mental health hospital after staff failed to conduct a "proper and lawful" search of him and other patients on his ward say they're "devastated" by their loss.

An inquest into the death of Stefan Barrie Walker was held at Swansea Coroner's Court before assistant coroner Edward Ramsay and a jury of 10 members of the public, concluding on Tuesday, 28 May.

The inquest heard Mr Walker died in his bed at Cefn Coed Hospital in Swansea in the middle of the afternoon on 29 June, 2020 - and concluded that his death could potentially have been avoided if hospital staff had searched him and other patients on his ward following his return from a brief period away from the hospital.

The inquest into Mr Walker's death was first opened in July 2020 but was paused until May 20, 2024.

On the first day of the resumed inquest, Swansea Coroner's Court heard Mr Walker's family will remember him for his "larger-than-life personality" and "huge character," and also heard a detailed history of Mr Walker's mental health diagnoses, along with a recount of how Mr Walker came to be under the medical care of Cefn Coed mental health hospital.

After hearing evidence from medical professionals and people involved in Mr Walker's care, assistant coroner Edward Ramsay formally closed the inquest into Mr Walker's death on Tuesday, May 28, 2024.

The record of inquest gives Mr Walker's medical cause of death as "buprenorphine and flualprazolam intoxication and cardiac enlargement" and gives an overall conclusion of a drug-related death.

Explaining the circumstances of Mr Walker's death, the record reads: "Stefan died in his bedspace at Cefn Coed Hospital, Swansea on June 29, 2020 sometime between 3.20pm and 3.45pm."

An additional statement explains further: "The death of Stefan Barrie Walker occurred due to the effects of self-administered illicit substances in conjunction with an enlarged heart.

"Stefan had mental health issues which were amplified by his use of illicit substances. This contributed to his intoxication due to the taking of these substances.

"Staff knowledge of search policy relating to illicit substances was inadequate. Escorted ground leave was granted and routine observations were taking place. A full physical health check took place on June 28, 2020 conducted by an on-call general practitioner.

"As a result of this check, observations were recommended at 15-minute intervals along with monitoring of blood pressure and respiratory rates for the following six hours. These recommendations were followed.

"On June 29, 2020, following review by medical staff, Stefan was exhibiting the same presentations as June 28, 2020, and as such no further actions were deemed to be required apart from reducing observations from 15-minute to 30-minute intervals."

Further comments on the record of inquest stated that if staff had checked Mr Walker and others for drugs after he returned from "ground leave" away from the hospital's premises, which they did not do, Mr Walker's life could have potentially been saved.To the question "was there a failure to conduct a proper and lawful search of Stefan and others on Fendrod Ward at Cefn Coed Hospital for illicit substances following his return from ground leave on 28 June 2020, in a way which might potentially have saved his life?" the jury stated "yes".

However, to the query "was there a failure to carry out a full physical health check on Stefan, including a properly calculated 'NEWS' score, before his death on June 29, 2020, in a way which might potentially have saved his life?" the jury stated "no".

Stefan Walker's mother, Christina Clancy, and his siblings said: "Stefan Walker was our son and our brother. He was a larger-than-life character with a huge personality. Stefan was also complex and suffered from a number of mental health issues.

"On June 29, 2020, whilst under the care of Cefn Coed Hospital, a mental health facility in Swansea, where he was a residential patient, Stefan died from an overdose. During the inquest at Swansea Coroner's Court, we have heard about the failures of those tasked with looking after Stefan to put measures in place which we feel could have prevented Stefan's death.

"In particular, the inquest found that there was a failure to conduct a proper and lawful search of Stefan and others on Fendrod Ward at Cefn Coed for illicit substances following his return from ground leave on June 28, 2020 in a way which might potentially have saved his life.

"As a family, we have been left devastated and there is a huge hole in our lives. This should never have happened and had these searches been conducted, Stefan may still be with us today.

"We were pleased to hear that Cefn Coed have carried out an independent review and implemented a number of changes. Sadly, these have come too late for Stefan.

"We have also been shocked by the lack of mental health facilities. In Wales, there is only one facility that offers the type of treatment that Stefan needed and that is a private hospital. There is no provision on the NHS in Wales.

"We are determined that Stefan's death will not have been in vain and are determined to fight for treatment to be more readily available, so that people have access to the appropriate help and no other family needs to go through what we have. We would like to pass on our thanks to our legal team and also to the coroner."

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