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Investigation and inquest
The inquest into the death of William Savory was opened on 5 March 2020. The inquest was resumed on 25 April 2022 and the conclusion was handed down on 29 April 2022.
The medical cause of Mr Savory’s death was:
1a. Acute Alcohol Toxicity
The inquest concluded with the conclusion of ‘Alcohol-Related Death’.
Circumstances of the death
Mr Savory was a 31 year old man who had been diagnosed with Mixed Personality Disorder.
On 17 January 2020 he had been released from a term of imprisonment at HMP Highdown and was of no fixed abode.
On 18 January 2020 he was admitted as an informal patient to the Abraham Cowley Unit (ACU), which is a psychiatric hospital run by Surrey and Borders NHS Foundation Trust (SABP). The purpose of his admission was to keep him in hospital for a week to observe and assess him, to trial him on an anti-psychotic medication, to support him to obtain housing and to refer him to Community Mental Health Team for support on discharge.
On 26 January 2020 Mr Savory left the ACU to go into the grounds for a cigarette at 18:10 but he did not return at the agreed time of 18:35.
On the morning of 27th January 2020 Mr Savory was found deceased in a shed which had been converted into a bar at his parent’s home address.
His death was due to acute fatal alcohol toxicity and was the unintended consequence of drinking a significant amount of alcohol including two bottles of ████████
Coroner’s concerns
SABP’s written policies require staff to commence missing person procedures immediately, yet the Coroner is concerned that not all staff are aware of this requirement. The Coroner therefore invites SABP to consider additional training or other measures to raise awareness of this requirement amongst all levels of staff including Health Care Assistants.
Information checked against the published report and official responses