Lewis Robert BEGLEY · Prevention of Future Deaths report

On 29 December 2020 I commenced an investigation into the death of Lewis Robert BEGLEY aged 35. The investigation concluded at the end of the inquest on 13 September 2022.

The medical cause of death was:
1a) Central Nervous System and Respiratory Depression
1b) Combined Drug Toxicity
1c)
2)

The conclusion of the inquest was:
Misadventure and Neglect contributed to the cause of death.

Mr Begley was placed on Section 2 of the Mental Health Act and admitted to Samphire Ward, Chatterton House on 12 December 2020. He was placed on 4 times per hour observations when in communal areas and generally hourly observations when he was in his bedroom. Mr Begley was seen to be acting in a suspicious manner during the early hours of 15th December 2020 whilst in the communal area. On 15th December 2020, Mr Begley gained access to the medicine room between 02.29 and 02.29.23 and again between 02.31.10 and 02.45.11. Upon being found in the medicine room, there was a failure to escalate risk to relevant persons. In addition, consideration was not given to further safeguarding checks in ensuring Mr Begley's safety. Multiple policies and practices were not followed adequately including the: Therapeutic Observations Policy, Searching Policy, Management of Medicines Policy. Inaccurate and inadequate information was handed over to other members of staff on shift and coming on shift. On the morning of the 15th December 2020, Mr Begley was found unresponsive in his room. CPR was commenced by staff. Emergency Services attended and Mr Begley was pronounced dead at the scene. At post mortem, a split plastic bag, containing 2 [████████] in addition to other tablets of shape, colour and size which were unidentifiable, were found in Mr Begley's rectum.

1. Evidence was heard that medication is kept in a locked room and in locked cabinets, in accordance with legislation. However, there is no record kept as to what medication is stored and how much, particularly ████████ which is a drug subject to misuse, in a mental health hospital where many patients have a history of drug misuse and suicidal ideation and actively seek out the drugs cupboard.
2. On a patient accessing medication, there is no knowledge as to whether anything has been taken and if so, how much, thereby limiting knowledge as to what treatment is to be considered and what action to be taken
3. Evidence was heard that there is no fixed training given to doctors with regard to the administering of ████████ in the event of there being a suspected drugs overdose.