Huw Irwin ERASMUS · Prevention of Future Deaths report

On 01 December 2022 I commenced an investigation into the death of Huw Irwin ERASMUS aged 34. The investigation concluded at the end of the inquest on 05 December 2024. The conclusion of the inquest was that:

Narrative Conclusion

Narrative Conclusion - Huw Irwin Erasmus was at risk of eating vegetation present in the grounds of the Aderyn Unit in Pontypool. Huw died from the toxic effects of consuming a large quantity of Yew leaves in the grounds. Those responsible for his care ought to have known that Yew trees were present, and the leaves were highly toxic and could be fatal if ingested. His death was an accident but it was contributed by a failure of those responsible for his care to identify and manage the risks associated with the ingestion of Yew leaves.

Huw Irwin Erasmus died on 11/11/2022 at Aderyn Unit in Pontypool where he was detained under Section 3 of the Mental Health Act.
Huw died from the toxic effects of consuming a large quantity of Yew leaves. Huw did not consume the leaves with the intention of ending his life.

Huw was detained at Aderyn Mental Health Hospital from 8/8/2022 to 11/8/2022 under Section 3 of the Mental Health Act. During that time he was granted unescorted leave within the grounds of the hospital. Huw had a propensity to ingest vegetation and it was a condition of his leave that he refrain from so doing.

The expectation according to the policy and from staff who gave evidence was that Huw would be assessed following a period of leave. It was also anticipated that this assessment would on occasion include a review of whether Huw had ingested vegetation.

There was no documentary evidence in the clinical records that Huw had been so assessed after a period of unescorted leave. There was also confusion amongst staff about the nature of the assessment and the level of documentation required.

Ultimately, the issue was whether in fact these assessments had taken place at all. Although in the circumstances this was not a finding made by the jury, it raises the concern that a failure to understand the requirements of a post-leave assessment and suitably document the findings could result in future deaths.